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About your discharge

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The following is a checklist to help you think about the arrangements and support you as a patient may need when you leave hospital. This is called ‘discharge planning’.

What is discharge planning?
For most people, leaving hospital is simple, but for some it can be more complicated. Planning for leaving hospital should begin as early as possible because arrangements for care and support will take a while to put into place.

The Senior Charge Nurse has lead responsibility for discharge arrangements. The Senior Charge Nurse is the main nurse in charge of the ward. They can signpost you to the ‘named person’ for your discharge planning, and give you information about local organisations and services. They also make sure referrals to other services are made at the right time and for the right reasons. This is the best person to speak to about your discharge planning.

A lead consultant has responsibility for checking if a patient is clinically fit to leave hospital. The decision for setting a discharge date is usually taken by the multi-disciplinary team as a whole, not just one member of staff.

If your admission is planned, information should be collected before you go into hospital, outlining if other services are already involved. Often though, people go to hospital as an emergency. If this happens, discharge planning usually starts at the time of admission. You will also be asked who your main carer is.

A ‘discharge plan’ will be made about the support you may need when you leave hospital. If applicable, you may wish your carer to also be involved in your plan. Staff will also ask you about issues or problems that might affect you once you leave hospital.

Between one and two days before discharge, you should know roughly what time you will leave the hospital. You will also be asked who has been arranged to help you return home (e.g. family member, friend, carer). If you require patient transport to return home, this can be arranged for you by informing the Senior Charge Nurse. On the day of discharge, you may have to wait for medication or transport.

Please ensure that before you leave the hospital you have what you need to return home safely, e.g. house keys, heating already switched on and/or sufficient fuel indoors to use, and foodstuffs.

By the time you leave hospital you should know:

  • how to contact relevant services
  • what treatment will be provided
  • what services will be provided and when, and the cost of these
  • how to use any equipment needed
  • what, when and how, your medication should be taken.
Home First
While the hospital is the best place for medical checks and treatments, it’s not the best place to recover once you’re well enough to go home. Staying in hospital when you’re well enough to go home can:
  • reduce independence
  • reduce muscle strength
  • and increase your risk of infection.
By recovering at home, you reduce the chance of physical and mental health problems which can occur when you spend too much time in a hospital bed. Being at home can also reduce the risk of infection and let you get back to your usual routine.
How does Home First work in practice?
 
Discharge Planning
Planning for discharge begins as soon as you are admitted to the hospital. The goal is to discharge you once your medical needs can be met outside the hospital, which is crucial for patient wellbeing.
Discharge Plan
A discharge plan should be in place before you leave the hospital, covering your medical condition, medications, ongoing treatments, and any required services or equipment. Family members or carers and crucially, you as the patient are entitled to be involved in this planning process.
Assessment
You will work with your medical team to determine when you’re ready to leave hospital. This team may include doctors, nurses, social workers, occupational therapists, and other specialists such as physiotherapists and dieticians.
Discharge Options
Based on the assessment, several discharge options are considered:
  • Immediate discharge with little or no ongoing care needs
  • Discharge with short-term support, known as reablement care
  • Discharge with long-term care needs, which will involve creating a care and support plan
  • Discharge to step-down or intermediate care for intensive short-term support
Types of Discharge
  • Home with Short-term or No Care Needs: Local councils may arrange short-term care.
  • Home with Long-term Care Needs: A care and support plan will be developed, detailing the services provided and associated costs.
  • Step-down Care: For those who need intensive support temporarily, care may be provided in residential settings or at home.
 
Care Home Discharge
If returning home is not feasible, the council may recommend residential care. You have the right to choose a care home, provided it meets your needs, is willing to accommodate you, and costs within the council's expected rates.
 
Paying for Care
Costs for care vary by council area. Personal and nursing care is provided free if assessed as needed. Charges may apply for domestic assistance, and a financial assessment will determine your contribution.
 
Self-Directed Support
Self-Directed Support allows you to choose how your care budget is spent, offering options from direct payments to council-managed services.
 
Preparing for Discharge
Before leaving the hospital, ensure:
  • You have necessary personal items and a way to get home
  • You understand your medications and have a supply
  • Any required equipment is ready, and you know how to use it
  • You know the local support available, and your GP is informed
Care at Home (otherwise known as Home Care)
Self-Directed Support
START

If required, you could be referred to and receive support from the START Occupational Therapist and Physiotherapist and if you meet the eligibility criteria of the START service, input from Reablement Workers may also be available.

The START team consists of:

  • Reablement support workers
  • Care and Support Supervisors
  • Occupational Therapists
  • Physiotherapist

Reablement can be provided to patients on average for six weeks and your level of support will be adjusted to suit your particular needs. You will be supported through your discharge by your ward's Senior Charge Nurse. If you have worries about going home please tell the Senior Charge Nurse.

Click here to view our handy START information leaflet. 

Please note that the six-week reablement programme is only available within the Isle of Lewis due to geographical constraints and the size of the team.