HOSPITAL TO HOME CARE- Helping you return home from hospitaL

Support Options

The type of support that you require upon hospital discharge will depend upon your needs and preferences, however the care plan agreed with you by the hospital staff may include:

• Care and support from a private provider that you pay for either in your own home or a care home – this is likely to be the only option if you aren’t eligible for help from the local authority
• Community care services from the local authority, such as reablement services – an assessment for these must be arranged if it seems that you may need them
• NHS continuing healthcare – NHS funded care for somebody with a ‘primary health need’
• NHS funded nursing care – provided by a registered nurse and only if you are in a care home
• Intermediate care – this is short-term care that’s provided free of charge for people who no longer need to be in hospital but may need extra support to help them recover. It lasts for a maximum of six weeks and can be provided in someone’s home or in a residential setting
• Other NHS services – such as rehabilitation or palliative care
• Equipment – such as wheelchairs, specialist beds, or aids and adaptations for daily living

The decision to transition into a care home following a hospital stay or to return to the familiar surroundings of your own home should be based around the wishes of the patient and their individual needs. Many elderly people prefer to discharge into their own home with the support of a professional home care team where their care can be individually tailored to their specific needs, often involving specialist input from health professionals such as a District Nurse, physiotherapist or occupational therapist. This can be on an hourly basis where carers will come at various times during the day, or a full-time or live-in basis to ensure support around the clock. There are many benefits to recovering in your own home including a smoother transition, familiarity, confidence, tailored activities and more personalised one-to-one care.

On the day of discharge, the person coordinating the discharge should make sure that:

• you (and a carer if you have one) have a copy of the care plan
• transport is arranged to get you home
• any carers will be available if needed
• your GP is notified in writing
• you have any medication or other supplies you’ll need
• you’ve been trained how to use any equipment, aids or adaptations needed
• you have appropriate clothes to wear
• you have money and keys for your home

After hospital discharge your care will be monitored as set out in your care plan.

To determine if and what type of care you may need to be discharged from hospital a discharge assessment will be completed. This could be carried out by a team of health and social care professionals, especially if your needs are more complex, including (but not limited to) a hospital consultant, nursing staff, a social worker, a physiotherapist or an occupational therapist. You should be involved in this process and your views, and those of your family, listened to.

If you are to return to your own home with support from a home care provider you should inform them of this process so as they can be involved as required and make plans for your care. The discharge assessment may also include an assessor viewing you in your own home to understand how you will cope upon your return.

Following the completion of a discharge assessment by the health and social care professionals in hospital a care plan will then be drawn up, detailing the health and social care support for you. The care plan should include details of:

• the treatment and support you will get when you’re discharged
• who will be responsible for providing support, and how to contact them
• when, and how often, support will be provided
• how the support will be monitored and reviewed
• the name of the person who is coordinating the care plan
• who to contact if there’s an emergency or if things don’t work as they should
• information about any charges that will need to be paid (if applicable)

Important Tips

• Research and understand your options as early as possible – if you wish to return to your own home ensure that this is made clear to your discharge team
• Keep your chosen care provider updated – ensuring that you provide sufficent warning and information enables them to plan and properly support a safe discharge and recovery
• Obtain an updated list of your medications – these may have changed during your stay in hospital and it is important that you both have the correct medications upon discharge and your pharmacist, GP and / or care team can ensure your ongoing prescriptions are correctly provided
• Home aids and equipment – you may have been provided with these which need to be available / installed and your care team may need to be trained in using them
• Understand your physical limitations – be aware of what daily activities your hospital discharge team advises you are capable of and what is considered ‘high risk’ or ‘unsafe’
• Make arrangements for your discharge day – consider how you will return home or if hospital transportation will be required. Also think about what you will wear and how you will access your house (e.g. do you have keys)