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. You may also choose to involve a private nurse, who can provide one-to-one clinical support and continuity of care once you return home.

The hospital discharge team

To alleviate stress and ensure a smoother experience, it is useful to familiarise yourself with the roles of professionals involved in hospital discharge planning:

Discharge coordinator

Ensures a seamless transition by liaising with your doctors, nurses, and any external care agencies to conduct a thorough assessment of your needs. They also facilitate arrangements for transport, 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 your care after hospital discharge.

District nurse

District nursing plays a vital role in providing care to clients in their own homes. District nurses can carry out dressings, provide catheter care and administer medication. They can undertake assessments and deliver care directly, ensuring clients receive personalised support tailored to their conditions. At your request, a member of the District Nursing team will visit to provide appropriate care and assistance with any concerns you may have.

Charity and specialist nursing

If you require specialist care, such as end-of-life support, charities such as Macmillan or Marie Curie can offer a limited amount of free nursing care. Referrals typically come from your District Nurse, GP or discharge co-ordinator. Following referral, a nurse will assess your needs and create a care plan. You may be eligible for up to three months of palliative care and up to four one-hour visits per day. When you contact these organisations, they will advise what level of support they can provide.

Community care providers

GP

Your General Practitioner plays a vital role in your hospital discharge by reviewing your treatment plan, co-ordinating care between hospital and community services, collaborating with other health care providers, and advocating for your needs. Your GP will be your central point of contact once you return home and can provide referrals to District Nurses, charities, social services, specialists, or occupational therapists.

Social services/social care

Following hospitalisation, you may be eligible for up to six weeks of care, usually comprising hourly visits. They may also support you with equipment and home adaptations. To enquire about what you may be entitled to, you should speak to your GP.

People with long-term or complex care needs may qualify for social care arranged and funded by the NHS, known as Continuing Healthcare. You would be assessed by a multi-disciplinary team who would review all your needs to determine whether you qualify and, if so, develop a tailored care package.

Rehabilitation and support specialists

Physical and occupation therapists

These professionals assess your mobility and functional abilities, helping you to maintain as much independence and quality of life as possible by developing a personalised rehabilitation plan. In some circumstances, you can access therapy through the NHS with a referral from your GP.

Dietitian or nutritionist

A dietitian or nutritionist can support you with dietary recommendations and meal planning, particularly if your condition requires specific nutritional considerations. A speech and language therapist may also assess you in hospital and provide specialist advice on how to modify your diet if you have restrictions around eating or drinking.

Care management and coordination

Case manager

A case manager may be appointed to ensure all aspects of your care and discharge plan are managed effectively. They are typically provided by private companies but may also be available through the NHS. You can choose to appoint a case manager to support your transition from hospital to home, as they are specialists in navigating the health care system on your behalf.

Private care agencies

Private care agencies can guide you through planning your discharge and provide a skilled nurse or carer to support you at home. Services may include medication management, help with daily activities, wound care after surgery, and much more. Private agencies give you the flexibility to decide how much care you receive, when you receive it, and who provides it, allowing you to adapt the care to your specific needs.

Palliative team

If you require palliative care, you will meet the hospital’s palliative care team, which typically includes consultants, specialist registrars, clinical nurse specialists and psychological professionals. They will discuss your options, such as receiving care at home or entering a hospice. The team works with you and your loved ones to co-ordinate care and provide advice and referrals.

How can Cavendish Homecare help?

At Cavendish Homecare we are experts in providing private nursing 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, 02030085210 or email us at info@cavendishhomecare.com.

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