The discharge plan
The discharge plan is the outcome following discussions in hospital between a team of healthcare professionals. Each patient should be given one before leaving hospital.
A patient’s care shouldn’t end the minute they leave hospital. All hospitals should have plans in place to help your loved one with the transition from hospital to home or care home. Each hospital will have its own policy and arrangements for discharging patients and should provide information about this.
A hospital social worker and possibly a reablement team (also known as the discharge coordination team) are likely to be involved in planning ongoing care.
The professionals in charge of your loved one's care should draw up a discharge plan in discussion with both the person you care for and you. They will ask questions so they can assess their needs and find out what support is needed for when they go home. These questions may include:
- Can you manage steps or stairs?
- How do you manage with personal care, such as bathing and washing?
- Can you prepare your own meals?
- Do you need any financial support?
This plan should be drawn up within 24 hours of admission to hospital, however in reality it’s more likely to be drawn up once discharge is on the horizon, especially if they’re going to be in hospital for a while.
It should outline who will be involved with ongoing care after leaving hospital. Importantly, it should also tell you who to contact for help and support once the person you care for has returned home.
Your loved one may need ongoing care from a number of different organisations and healthcare professionals. If they do, a liaison nurse, nurse discharge coordinator or assessment officer from the reablement team will manage the arrangements for when they go home.
When it's time to be discharged
The person you care for should only be discharged from hospital:
- when their doctors are happy that they are well enough to go home, and
- when they have appropriate care in place so they can manage safely at home or move to a care home.
They should not be discharged in the middle of the night nor without adequate arrangement for transport. If you don’t agree with the decision to discharge or with the discharge arrangements, speak to the nurse in charge of the team.
Your loved one has the right to discharge themselves from hospital at any time, but you should speak to them and the medical team if you feel they’re doing this before they’re ready.
If you’re unhappy with a suggested discharge date, raise your concerns with the hospital staff.
The needs assessment
If your loved one has been seriously ill or has suffered a fall, they may require care once they return home. If this is the case, they should be allocated a hospital social worker, occupational therapist or other member of staff who will assess their needs and discuss a suitable domiciliary care package to help once they are discharged from hospital.
The hospital healthcare specialist will arrange for the assessment to take place either while your loved one is still in hospital or, if there is a six-week NHS Intermediate Care package involved, before the six weeks is up. Once their needs have been assessed, staff should discuss the options for meeting them and should produce a care plan detailing the assessed needs.
In Scotland, every NHS Board and each local council’s social work department should have a special arrangement in place for the discharge of patients. In many NHS Health Board areas, the process is called a Single Shared Assessment.
Intermediate Care is provided in Scotland, but the length of time will vary depending on the circumstances.
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