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Integrated Care Pathways

Joined-up community rehabilitation across Yorkshire. We combine ABI Rehabilitation, Independent Living Trials, Complex Care, and Staffing into one coordinated pathway. Our trained Rehabilitation Support Workers and Qualified Nurses follow a single plan, share a risk framework, and report outcomes on one cadence.

Our team brings frontline experience from some of the UK’s leading brain injury hospitals. That experience shapes our standards for safety, training, supervision, and governance across every phase.
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Seamless, evidence-based rehabilitation and care coordination across Yorkshire.

What We Provide

Every phase follows the same governance, reporting cadence, and safety framework for consistency.

Integrated Team and Single Plan

One pathway with shared goals, one reporting schedule, and a single contact for case managers and families.

Phased
Rehabilitation

Start with ABI Rehabilitation, move into an Independent Living Trial to evidence needs, then stabilise with Complex Care as required.

Consistent
Staffing

Rehabilitation Support Workers and Qualified Nurses matched to risks and goals, with continuity during transitions.

Shared Risk Framework

One risk register carried through all phases covering falls, medication, behaviour, safeguarding, community access, and environmental safety.

Outcome Reporting

Recognised measures and narrative reporting that continue across phases, so progress is clear and decisions are easier.

Flexible Capacity

Staffing that adapts to peaks, nights, and changing needs without breaking the pathway or the relationship.

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Benefits & Outcomes

Our integrated approach reduces risk, improves continuity, and drives measurable recovery outcomes.

For Professional Partners

  • Single provider coordination reduces duplication and gaps.
  • Structured risk management tailored to each phase of care.
  • Outcome metrics that matter: reduced incidents at transition points, clear evidence for support hours, measurable functional gains.
  • Timely reports aligned to commissioner, tribunal, or insurer requirements.

For Families and Clients

  • Fewer handovers and familiar faces.
  • Routines and care plans that develop as needs change.
  • Visible improvements in daily living, confidence, and community participation.
Discuss an Integrated Case

How It Works

Ready to build your integrated care plan? Start a referral below.

01 - Referral

What happens

We review goals, risks, timescales, current provision, and required phases.

Outcomes

Feasibility confirmed and a draft integrated pathway proposed.

02 - Assessment

What happens

Baseline function and risk analysis in home or hospital, with phase planning.

Outcomes

Staffing recommendations and a single care plan with review points.

03 - Implementation

What happens

Staff inducted, reporting cadence agreed, communication lines set.

Outcomes

Safe start with consistent delivery across services.

04 - Phase Transition

What happens

Planned handover between phases with staff continuity and shared risk register.

Outcomes

Stable transitions and preserved gains.

05 - Review & Reporting

What happens

Rolling quantitative measures and narrative reports across phases.

Outcomes

Evidence-based adjustments and clear decision support for commissioners.
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Case Studies

Hospital to Home in Five Months

Integrated step down • ABI Rehab → ILT → Complex Care

Background and Risks

Adult with severe TBI ready for discharge but high fall risk and uncertain support hours. Family anxious about night-time safety.

Pathway and Interventions

ABI Rehabilitation to build routine and safety awareness. Independent Living Trial to evidence support hours and night risk. Complex Care to stabilise and embed routines.

Results and Evidence

Falls incidents reduced month on month. Medication adherence reached 95 percent. Support set to 1:1 with targeted 2:1 windows. Family reported improved confidence and fewer crisis calls.

Support model: 2:1 targeted → 1:1 core with planned peaks
Pathway duration: 5 months

Community Stabilisation With Step Down Staffing

Behaviour support • Complex Care → targeted ABI inputs

Background and Risks

Learning disabilities and autism with escalating incidents in the community. Sleep pattern unstable. Multiple rota changes.

Pathway and Interventions

Complex Care with recognised challenging behaviours approaches and predictable routines. Focused ABI inputs embedded in daily tasks. Planned step down in staffing.

Results and Evidence

Incidents down 40 percent from baseline at 16 weeks. Independent travel to a familiar location achieved. Staffing reduced by 8 hours per week with safeguards.

Incident trend: −40 percent
Staffing: reduced by 8 hrs/week

Evidence for Long-Term Provision

Commissioner decision support • ILT informing package size

Background and Risks

Unclear support hours and questions about night cover. Concern about community access triggers.

Pathway and Interventions

Time-limited Independent Living Trial with baseline vs end-of-trial comparison, incident analysis, and PBS-aligned strategies.

Results and Evidence

Clear evidence set sustainable support hours. Night cover allocated to key windows only. Community access maintained twice weekly without incidents for four consecutive weeks.

Outcome: sustainable hours approved
Community access: stable 2x/week

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FAQs

Can we combine services?
Yes. ABI Rehabilitation, Independent Living Trials, Complex Care, and Staffing can be combined and phased to match need.
We use a single care plan, shared risk register, and one reporting cadence with a single point of contact.
We use recognised measures and structured narrative reporting carried through each phase so change over time is clear.
Yes. We implement therapy goals set by external MDT members and align our reporting schedule with theirs.
Yes. We implement therapy goals set by external MDT members and align our reporting schedule with theirs.

What people say about Greenshoot

Ruth – Case Manager, CCMS Case Management

I have found working with Greenshoot to be an entirely positive experience. They are extremely responsive. If concerns arise, they highlight them in a timely manner, and communication with the office team is efficient. The specialist support staff provided to my client have been professional, skilled at building a positive working relationship after a stressful experience, and proactive in contacting me when required.

Stephen

I have been working for Greenshoot care services for approximately 2 months now. I really appreciated the welcome and already feel I am a valuable member of the team. Staff are very friendly, supportive and easily accessible. I have 20 years experience in the nursing field and I must admit this is the best agency I have worked for. There are plenty of shifts and they are very flexible with holiday pay. Training is also available tailored to the type of settings you enjoy working. There is support for personal development. I do strongly recommend anyone to join this agency. Big thanks to Michelle, Emma and Sophie.

Lucy Moore

I have worked for Greenshoot for about 18 months and they are fantastic. The whole office team are really efficient and super friendly. I feel really supported there. I feel like they really care about their staff and the clients they support. They give good training and put you in roles that you feel confident in.
As a student I find the role really great as it is flexible. The team are really great if I have exams coming up and want to work less or am on holiday and want to work more. I feel like they want me to succeed both at work and in my degree which is really nice. They always pay correctly and on time. The pay is also weekly which is really useful for me.

Lisa – Case Manager, CCMS Case Management

I have found the communication and flexibility of your services for my client exceptional. All staff I have dealt with have been professional, very accommodating of changes at short notice, cascading information and working collaboratively to provide a client-centred service. The attention to client needs and selection of support staff to match has been thorough, and the approach of the support workers in the package has been key in the client accepting formal support. Thank you to you all for your continued support on this case.

Lesley – Abbeyfield York Society

The quality of staff you provide as an agency is excellent

Katy – J’s PA, rota organiser, and most importantly, big sister.

We’ve been using Greenshoot Care Services since April this year, and they joined us during an incredibly difficult time in our family’s life.

The gentleman they support, J, was experiencing significant mental and physical health challenges, and Greenshoot stepped in right in the middle of it all. To say a fog lifted would be an understatement. They immediately brought calm, stability, and reassurance — not just to J, but to our whole family and the other carers involved.

Since then, a wonderful friendship has grown between J and his support team. His mental and physical health have both improved dramatically — a change that’s due in no small part to Greenshoot’s commitment and care.

Trust doesn’t come easily for J, yet the team earned it within just a few months. Their professionalism, kindness, and ability to stay calm under pressure have been truly refreshing.

If it weren’t for Greenshoot Care Services, our lives would look very different today.

Thank you, from the bottom of our hearts, for the outstanding support and care you’ve provided.

Richard – Unit Manager York

I just wanted to say how happy I am with the service provided by Greenshoot Care Services. You are by far the best agency provider I’ve ever worked with.

The staff you’ve supplied have been exceptional — professional, reliable, and a real pleasure to work alongside. They’ve quickly become part of our team, and it’s an absolute joy to have them on board.

I also want to thank the Greenshoot office team for their continued support and flexibility. You handle last-minute changes and busy periods with such professionalism and understanding, which makes managing our service so much easier.

Thank you to everyone at Greenshoot Care Services for your excellent communication, teamwork, and commitment.

Get Started?

Professional partners can refer a client or request an assessment below. Families are welcome to contact us for guidance.
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