The discharge plan
A patient’s care shouldn’t end the minute they leave hospital. Whether your hospital stay was planned or the result of an accident or emergency, you may need extra support to help you settle back into your daily life.
All hospitals should have a procedure in place to help with the transition from hospital to home, or to a care home. You should be given information about the hospital’s discharge arrangements as early as possible during your stay.
Each patient should get a personalised discharge plan before leaving hospital. This will be drawn up by a team of healthcare professionals and will take into account your physical condition, care needs and living arrangements.
The team should discuss the discharge arrangements with you or a family member or carer who looks after you. They will carry out an assessment to find out what support you need for returning home. This may include questions such as:
- How do you manage with personal care, such as bathing and washing?
- Can you prepare your own meals?
- Can you manage steps or stairs?
- Do you need any financial support?
Ideally, the discharge plan should be drawn up within 24 hours of admission to hospital, however in reality it’s more likely to be completed once discharge is on the horizon, especially if you’re going to be in hospital for a while.
The discharge plan should include:
- information about your health condition and any medication you need
- details of any ongoing social care or healthcare support you require to return home safely, and who will be involved with providing this
- who to contact for help and support once you’ve returned home
- details of other community services or voluntary organisations who can help.
You should be given a copy of the plan before you leave hospital; a copy should also be sent to your GP and to a care home, if you live in one.
If you do need extra support on leaving hospital, a social worker and possibly a reablement team (also known as a discharge coordination team) are likely to be involved in planning your care. You may need support from a number of different organisations and healthcare professionals. If that’s the case, a liaison nurse, discharge coordinator or assessment officer from the reablement team will manage the arrangements for when you go home.
When it’s time to be discharged
You should only be discharged from hospital:
- when your doctors are happy that you are well enough to go home, and
- when you have appropriate support in place so you can manage safely at home, or move to a care home or other care setting.
You should not be discharged in the middle of the night nor without suitable transport arrangements to get home. If you’re unhappy with a suggested discharge date or with the discharge arrangements (for yourself or for a loved one), raise your concerns with the staff in charge of your care.
A patient has the right to discharge themselves from hospital at any time. However, if someone you care for wishes to discharge themselves, you should speak to them and the medical team if you feel they may be doing this before they’re ready.
As part of your discharge plan, it may be decided that you would benefit from temporary support to help you get back to normal and stay as independent as possible once you leave hospital. This is called NHS Intermediate Care, reablement or aftercare and it’s free for up to six weeks.
This temporary care will be arranged by the hospital social work team before you are discharged and will be outlined in your discharge plan.
Find out what support is available and under what circumstances in our guide to NHS Intermediate Care.
When you are assessed for leaving hospital, it may be decided that you need more than temporary support and that you would benefit from ongoing care at home or in a care home. If this is the case, you should be referred for a local authority needs assessment. The assessment is free, regardless of your financial situation.
A hospital social worker, occupational therapist or other member of staff will arrange for the assessment to take place, either while you are still in hospital or, if there is a six-week Intermediate Care package involved, before the six weeks is up. Once your needs have been assessed, staff should produce a care plan detailing your needs and discuss a suitable care package to help once you are discharged from hospital, or when temporary care arrangements have ended.
If you have a complex health condition which means you will require significant, ongoing health care after leaving hospital, you may be assessed for NHS Continuing Healthcare (CHC). CHC is a care package for people with complex medical needs that is fully-funded by the NHS.
The eligibility criteria for NHS CHC are complex. Find out more in our guide:
Hospital discharge in Scotland
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.
Find out more about support for leaving hospital in Scotland.
The Red Bag scheme for care home residents
The Red Bag scheme (also called the ‘Hospital Transfer Pathway’) helps care home residents admitted to hospital be discharged quicker. The bags contain key paperwork, medications and personal items such as glasses, slippers and dentures. Red bags are handed to ambulance crews by carers and travel with patients to hospital before being handed over to the doctor.
As well as giving reassurance to patients, the red bags ensure hospital staff are able to quickly identify the patient as a care home resident. Doctors are able to easily liaise with care home staff so the resident can be better supported when they are discharged.
The initiative started in 2015 in Sutton, south west London before being deployed nationwide in 2017. The scheme now covers around 80% of England.
A needs assessment is key to getting the support you need. You have a right to this assessment and it's free of charge.
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