Post-Hospital Care — What to do before transitioning back home

When a relative goes into hospital, 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. How will they transition?

Your relative’s care shouldn’t end the minute they leave hospital. Plans should be in place to help them with the transition from hospital to home. Each hospital will have its own policy and arrangements for discharging patients and should provide information about this. However, here are some general guidelines to help you prepare and ask the right questions.

Before your relative leaves for hospital

Preparation for planned hospital visits should happen before your relative is admitted. As well as details of any treatments or operations they might receive, you should also make sure that an estimated date of discharge is provided so you can make the necessary arrangements. 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.

Assessing care needs

If your relative has been seriously ill, undergone surgery, or has suffered a fall, they may well 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 and forms the basis of any and all follow-up care that your relative is found to be entitled to.

This kind of 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 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 own meals?
  • Is any financial support required?

It can take several days to plan a discharge, especially if a number of different services need to be arranged. But it will ultimately provide a much smoother transition for your loved one if staff know exactly what is required to help them stay happy and healthy once they return from hospital.

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 in 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.

Before discharge

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

  • Support at home has been agreed 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 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 care plan cover?

A care plan details the health and social care support your relative needs after they leave 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 cordinating 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 should also include details of who to contact if things don’t work as planned.

If the care plan includes any services from a local authority, it should include provision to check that their care package is working well within two weeks of your discharge. 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 of these questions on our FAQ page. Find out how Cavendish Homecare deliver exceptional care.

If you'd like to know more, or to discuss your requirements, please call +44 (0)203 008 5210

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