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:
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:
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.
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. It can happen in your own home, in a care home or in hospital.
NHS Intermediate Care is usually arranged by the hospital social work team before you’re discharged. But it can also be used to enable you to stay at home following an emergency disruption to care arrangements (for example, if the person supporting you has to go into hospital).
If you need further support after six weeks, you’ll be given a plan for transferring to another service. Ask your local authority’s social services for a free if you haven’t already been assessed. Staff should then 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. But you may have to start paying for it yourself.
If you have a complex health condition which means you will require significant, ongoing health care after leaving hospital, you could be eligible for . CHC is a care package for people with complex medical needs that is fully-funded by the NHS.
If you need to move into a residential care home and you don’t qualify for Continuing Healthcare, you might be eligible for . FNC is funding provided by the NHS to cover the cost of care by a registered nurse in a care home or nursing home.
District nurses work closely with GPs and can make regular visits to patients and their families at home. They provide help and advice with the practical aspects of nursing care, including wound dressings, injections, taking out stitches and managing stomas, catheters or feeding tubes.
District nurses can also arrange for certain equipment – such as a commode, bedpan or special mattress – to be used at home if needed. They can also assess your care needs in your home and refer you to help from other healthcare professionals. In some areas, district nurses can visit in the evening and at night-time.
If you need district nursing support, the ward nurse or discharge coordinator will contact the local district nursing service to arrange a home visit. They will also send the district nurse information about the care received in the hospital.
If you have mobility issues and would benefit from home adaptations or mobility equipment, you will need to be assessed by an occupational therapist (OT). Your ward nurse, key worker or a liaison nurse can arrange for an OT to visit you if this hasn’t already happened as part of a needs assessment.