Who is involved in the hospital discharge process?

During the hospital discharge process, you will have the opportunity to interact with a diverse team of professionals, each with unique expertise and abilities to assist you effectively.

The hospital discharge team

To alleviate any stress and ensure a smoother experience, it will be useful to familiarise yourself with the functions of these professionals who are involved in the hospital discharge planning process:

Discharge Coordinator

Ensures a seamless transition by liaising with your doctors, nurses, and any external care agencies to conduct a precise assessment of your needs and facilitate arrangements for transportation, medication, and necessary equipment. Once you return home, they will transfer your care package to your GP, district nursing team or any other specialist teams who will manage you care after hospital discharge.

District Nurse

District nursing plays a vital role in providing care to clients in their own homes. District nurses can do dressings, provide catheter care and administer medication. They can undertake assessments and deliver care directly to clients in their homes, ensuring they receive personalised care and support specifically tailored to their conditions. At your request, A member of the District Nursing team will be able to provide care they deem is appropriate in your home to assist you with any concerns or care you may require.

Charity/specialist nursing

If you require a specialist care, such as end of life care, you can get assistance from charities such as Macmillan or Marie Curie who will be able to offer a limited amount of free specialist care. A referral to one of these services typically would come from your District Nurse, GP or discharge co-ordinator. Following the referral, a nurse will assess your needs enabling the creation of a care plan. You may be eligible for up to 3 months of palliative care and up to four, one-hour visits per day. When you get in touch with these organisations, they will advise what level of support they will be able to provide.

Community care providers

GP

A General Practitioner plays a vital role in your hospital discharge by reviewing your treatment plan, coordinating care between the hospital and community services, collaborating with other healthcare providers and advocating for your needs. Your GP will be your central point of contact once you return home and can give you referrals and help you get in contact with other healthcare professionals such as a District Nurses, charities, social services, specialist referrals or occupational therapist.

Social Services/Social Care

• Following hospitalisation, you may be eligible for up to 6 weeks of care, typically these comprise of hourly visits. They may also support you with equipment and home adaptations. To enquire about what you may be eligible to receive, you should speak to your GP.
• People with long term or complex care needs may qualify for social care that is arranged and funded by the NHS, known as continuing healthcare. You would be assessed by a multi-disciplinary team who would look at all your needs to determine your care needs to develop a care package.

Rehabiliation and support specialists

Physical and Occupation Therapists

These professionals will assess your mobility, functional abilities and help you have as much independence and quality of life as possible by developing a personalised rehabilitation plan. In some circumstances, you can get occupational or physical therapy through the NHS. To enquire about this, you would need to get a referral from your GP.

Dietitian/Nutritionist

A dietitian or nutritionist can help you with dietary recommendations and meal planning, specifically if your medical condition requires special dietary considerations. A speech and language therapist may assess you in the hospital and will be able to give you specialist advice on how to modify your diet when you have restrictions on your means of eating or drinking.

Care management and coordination

Case Manager

A case manager may be involved to ensure all aspects of your care and discharge plan align efficiently. They are typically provided by private companies but can also be provided by the NHS. You can appoint a case manager to help support and manage your discharge from hospital to care at home as they are specialists at navigating the healthcare system on your behalf.

Private Care Agencies

A private care agency can provide you guidance when planning your discharge, they can then provide you with a skilled nurse or carer who can support you with, medication management, support with activities of daily living, wound care after surgery, and many other services in the comfort of your own home. Private care agencies give you the control to decide how much care you receive, the time you receive it and who provides that care, this allows you to adapt the care provided to your specific needs.

Palliative Team

If you require palliative care, you will be introduced to the palliative team at the hospital, this team typically consists of: consultants, specialist registrars, clinical nurse specialists and psychological professionals that specialise in palliative care. They provide you with options based on your condition such as whether you would like to receive care at home or to go into a hospice. The palliative team would be able to work with you and your loved ones in coordinating this and can give you advice and referrals. At Cavendish Homecare, we provide exceptional palliative and end of life care which can be provided in addition to the community palliative care services.

How can Cavendish Homecare help?

To make the most of your interactions with these professionals, don’t hesitate to ask questions, seek clarification, and express any concerns that you may have. At Cavendish Homecare, we can support your discharge from the hospital coordinate by guiding you through the process, working with other health care professionals, such as your GP, ensuring that you have all the necessary information, medication and equipment to ensure your transition from the hospital to home is as smooth as possible.

To learn more about our private homecare services and how we can assist with your hospital discharge, please reach out to our team at 020 3008 5210 or email us at info@cavendishhomecare.com. We are here to discuss further and address any questions or concerns you may have.