Post-hospital care: What to do before transitioning back home

____________________________________________________________________________________________________________________________________________

Key Takeaways

Plan from the point of admission

Discharge planning should start as soon as your relative enters the hospital, even for unplanned visits. Ensure you have the name and contact details of the staff member coordinating the move to help you prepare the home in time.

Understand the free needs assessment

If your relative’s health has changed, they are entitled to a free assessment. This determines if they need walking aids, home modifications, or a “reablement” care package, which provides extra support for up to six weeks during recovery.

Confirm the final checklist

Before leaving, ensure your relative has a clear care plan, a supply of new medications, and any necessary equipment installed at home. Their GP must be notified of the discharge to ensure medical support continues seamlessly.

____________________________________________________________________________________________________________________________________________

When a relative goes into hospital, whether for something routine or an unplanned visit, it can be a worrying time. As well as considering the treatment and care they receive, you must think about what will happen when it is time for them to return home. Your relative’s care should not end the minute they leave the hospital. Plans should be in place to help them with post-operative care at home. Each hospital will have its respective policies and arrangements for discharging patients, including the various healthcare professionals involved. However, here are some general guidelines to help you prepare and ask the right questions.

Before your relative leaves for the hospital

Prepare for planned hospital visits before your relative is admitted. Get details of their treatment and an estimated discharge date. This helps you make the necessary arrangements at home. The name and contact details of the member of staff coordinating the discharge should be made available to you.

Unplanned visits to a hospital as the result of illness or an accident, should also undergo discharge planning. Due to it not usually being anticipated, discharge planning usually begins on the day your relative is admitted and will follow a similar process.

Find out more about our post operative care services

Contact Us

Assessing care needs

If your relative has been seriously ill, undergone surgery, or has suffered a fall, they may require care once they return home. As part of the discharge process, your relative should be allocated a member of hospital staff who will assess their needs and discuss a suitable care package to help once they are discharged.

If your relative’s care needs have changed substantially from before their hospital stay, they should get a needs assessment. This assessment is free. It helps decide what follow-up care they are entitled to receive.

The assessment can recommend things like:

• Walking frames
• Help from a carer
• Changes to your relative’s home to help them manage day-to-day tasks

The needs assessment may also recommend moving your relative into a care home. The hospital staff can help to arrange the assessment, either while your relative is still in the hospital or before their six weeks of intermediate care is up. Once your relative’s needs have been assessed, staff should discuss the options for meeting them and should produce a care plan detailing the assessed needs.

Some of the questions or observations the needs assessment covers are:

• Can your relative manage steps or stairs?
• How do they manage with personal care, such as bathing and washing?
• Can your relative prepare your meals?
• Is any financial support required?

It can take several days to plan a discharge. This is especially true when coordinating different services. However, this effort ensures a much smoother move for your loved one. By understanding their specific needs, staff can ensure their continued happiness and health upon returning home.

Intermediate care and reablement

If your relative no longer needs to be in hospital, but still requires extra support to aid recovery, it is called intermediate care and or reablement. It lasts for up to six weeks and can be provided in your home or a residential setting. When this period of intermediate care or reablement finishes, your relative will be assessed to see whether any ongoing social care or NHS support is required.

Prior to discharge

Before your relative is discharged from the hospital the following requirements must be met:

• Support at home has been agreed upon and is in place.
• Services required for recovery or care are ready to start.
• Any home adaptations have been made, including appropriate equipment delivered or installed.

Before your relative leaves the hospital for home a member of staff who is responsible for overseeing the discharge should make sure:

• They have clothes to go home in, money and front door keys.
• You or someone else is collecting your relative, or a taxi or hospital transport has been booked.
• You have a copy of their plan.
• You understand any new medicines they’ve been given, and you have a supply to take home.
• You’ve been shown how to use any equipment, aids or adaptations they need.
• Their GP knows about their discharge and any extra help you need has been arranged.

If your relative is being discharged to a care home, the care home should also be told the date and time of your discharge and have a copy of your care plan.

What will a post operative care plan cover?

A care plan details the health and social care support your relative needs after they leave the hospital. You and your relative (if they are able) should be fully involved in making this plan. The care plan should include details of:

• Treatment and support your relative will get when they’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 (if applicable) to medications, treatments etc.

After discharge

Once your relative has returned home, been placed in a suitable care home or arrived at the place they will fully recover, the care they receive should be monitored and reviewed as set out in the care plan prepared for them. The care plan must include an emergency contact. If the local authority provides services, they should check on your relative within two weeks. For those living alone, this check should happen within the first few days. However, if your relative lives alone, this should take place within the first few days of discharge. After the initial review, the care plan should be reviewed at least annually.

Still have questions regarding the discharge process, transitioning home, or anything else? We have answered some FAQs page and this article outlines how we can support you during the discharge process.

How can Cavendish Homecare help?

At Cavendish Homecare, we are experts in providing post-hospital homecare for clients who want to remain in their own homes. When it comes to your health and wellbeing, choosing the right homecare package is of utmost importance and navigating this process can be overwhelming. With Cavendish Homecare by your side, you’ll have the support you need to remain safely at home while enjoying elevated health and wellbeing.

If you would like to enquire about our homecare services contact us on, 020 3008 5210 or email us at info@cavendishhomecare.com.