Care and support after discharge from hospital


The hospital discharge plan

A patient’s care shouldn’t stop the minute they leave the hospital. Whether your hospital stay is planned or the result of an accident or emergency, you may need extra support to help you get back into your daily life.

All hospitals should have a process in place to facilitate the transition from hospital to home or to a nursing home. You must be informed of the procedures for discharge from the hospital as early as possible during your stay.

Each patient should get a personalized discharge plan before leaving the hospital. This will be established by a team of healthcare professionals and will take into account your physical condition, your care needs and your lifestyle.

The team should discuss discharge arrangements with you or a family member or caregiver who cares for you. They will do an assessment to find out what support you need to get back home. This can include questions such as:

  • How do you manage personal care, such as bathing and grooming?
  • Can you prepare your own meals?
  • Can you handle steps or stairs?
  • Do you need financial support?

Ideally, the discharge plan should be established within 24 hours of hospital admission, but in reality it is more likely to be completed once discharge is on the horizon, especially if you are going to be hospitalized. for a certain time.

What should the exit plan contain?

The exit plan should include:

  • information about your condition and the medications you need
  • details of any ongoing social or health care assistance you need to get home safely, and who will be involved in this provision
  • who to contact for help and support when you return home
  • details of other community services or voluntary organizations that can help.

You should receive a copy of the plan before you leave the hospital; a copy should also be sent to your GP and to a nursing home, if you live there.

Organize additional support

If you need additional support when you are discharged from the hospital, a social worker and possibly a rehabilitation team (also known as a discharge coordination team) will likely be involved in planning your care. You may need the support of a number of different organizations and health professionals. If this is the case, a liaison nurse, discharge coordinator or assessment officer from the rehabilitation team will manage the arrangements for your return home.

Temporary care: NHS intermediate care and rehabilitation

As part of your discharge plan, it may be decided that you will receive temporary support to help you return to normal and remain as independent as possible after discharge from the hospital. It’s called NHS Intermediate Care, real or aftercare, and it’s free for up to six weeks.

This temporary care will be organized by the hospital’s social work team before your discharge and will be described in your discharge plan. This can happen in your own home, in a nursing home, or in a hospital.

NHS intermediate care is usually organized by the hospital’s social work team before your discharge. But it can also be used to allow you to stay at home following an emergency break in the care system (for example, if the person accompanying you has to be hospitalized).

Learn more about access free acute care from the NHS.

Longer-term support

If you need further assistance after six weeks, you will receive a plan to switch to another service. Ask the social services of your municipality free of charge needs assessment if you haven’t already been assessed. Staff should then produce a care plan detailing your needs and discussing an appropriate care package to help you after you are discharged from the hospital or when temporary care arrangements have ended. But you may have to start paying yourself. Read our guide to pay for home care for more information.

If you have a complex medical condition, which means you will need significant, ongoing health care after you leave the hospital, you may be eligible for NHS Continuing Health Care (CHC). CHC is a care package for people with complex medical needs fully funded by the NHS.

If you need to move to a nursing home and you are not eligible for continuing health care, you may be eligible for NHS Funded Nursing (FNC). FNC is funding provided by the NHS to cover the cost of care by a registered nurse in a nursing home or nursing home.

District nursing

District nurses work closely with general practitioners and can make regular visits to patients and their families at home. They provide help and advice on the practical aspects of nursing, including dressings, injections, removal of stitches, and management of ostomies, 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 home care needs and refer you to help from other healthcare professionals. In some areas, district nurses may visit in the evening and at night.

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 information about the care received at the hospital to the district nurse.

Mobility aids and home adaptations

If you have mobility issues and would benefit from home adaptations or mobility equipment, you will need to be assessed by an occupational therapist (occupational therapist). Your ward nurse, key worker or liaison nurse can arrange for an occupational therapist to visit you if this has not already happened as part of a needs assessment.

Once an occupational therapist has assessed your needs, they will take care of everything mobility aids or any other equipment needed to be available when you get home.

remember that home adaptations may take longer to organize, so as long as it is deemed safe to return home, you may be fired on the basis that adaptations will be made once you are home.

You may need to pay for these services, depending on your savings or income. A financial assessment will be undertaken by the local authority if you are deemed eligible for care following a needs assessment.


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