Arranging care after a hospital discharge

What should happen

Hospitals are under enormous pressure to free beds, and discharge planning frequently begins earlier and moves faster than families are told. That pressure is real and not malicious, but it means decisions sometimes get made at speed that are difficult to unpick later.

Before someone is discharged with ongoing care needs, there should be an assessment of what they will need at home and a plan to meet it. Where the situation is complex, that assessment involves social care as well as the hospital.

What you are entitled to ask for

• A discharge assessment. Ask who is carrying it out and when. Ask for it in writing.
• Reablement or intermediate care. A short period of intensive support at home, usually free for a limited period, aimed at helping someone regain independence after a hospital stay. It is frequently not offered unless asked for.
• An NHS Continuing Healthcare checklist. If the person's needs are substantially health needs, the NHS may fund all their care with no means test. You can ask for the checklist to be completed.
• An occupational therapy assessment for equipment and home adaptations - grab rails, a raised toilet seat, a perching stool, a hospital bed. Often available free and quickly.
• A Carer's Assessment in your own right, if you will be providing unpaid care.
• A direct payment, if the council will be funding care. This lets you choose your own provider rather than accepting whoever the council has contracted, and can usually be arranged even under time pressure.

What you cannot be made to do

You cannot be compelled to take a relative home without a care plan in place, and you cannot be required to provide care yourself. If you are told a discharge is happening and you do not believe it is safe, say clearly and calmly that you consider it an unsafe discharge, ask for that to be recorded, and ask to speak to the discharge coordinator or the hospital's PALS team.

Being polite and being firm are not in conflict. Write down names and times.

Moving quickly without agreeing to the wrong thing

1. Get the likely discharge date early

   Ask on day one, and keep asking. Even a rough date lets you start arranging rather than reacting.

2. Ask what the plan is, in writing

   Who assessed, what they concluded, what is being arranged and by whom.

3. Line up a provider in parallel

   Do not wait for the hospital to finish its process before speaking to care providers. A good provider can assess and be ready to start within 24 to 48 hours, but not within two hours.

4. Check the house before they come home

   Heating on, food in, bed downstairs if stairs are now a problem, trip hazards cleared, medication collected and understood, and a way to call for help.

5. Book a GP follow-up within a week

   Medication is very often changed in hospital, and reconciling it afterwards prevents a great many readmissions.

The first fortnight is the risky part

Readmission risk is highest in the first two weeks after discharge, and the common causes are mundane: medication confusion, dehydration, not eating, an untreated infection, or a fall in a home that has not been adapted for a person who is now less steady than they were.

This is precisely the period where daily visits earn their cost, even if the intention is that support will be temporary. Someone coming in each morning who notices that the tablets have not been taken and that no food has been eaten prevents most of the things that send people back.

Arrange discharge support → Or call 07539 535098 — tell us the discharge date and we will work backwards from it.