Let’s talk about discharge

Getting you out of hospital

We understand that you may be worried about leaving hospital, especially if you have been in hospital for a while. When you no longer need hospital care, it is better to continue your recovery out of hospital. Staying in hospital for longer than necessary may reduce your independence, result in you losing muscle strength and can lead to risk of infection. Leaving hospital as soon as you no longer require treatment in hospital will benefit your recovery, as well as allowing other patients to receive care at the right time. Hospital care is for people who are very unwell. Once you no longer need this, you may be transferred to a community setting to continue your recovery on a temporary basis, where your longer-term care needs and choices can be supported.

Who will plan my discharge from hospital?

Your hospital will start planning your discharge as soon as is possible. Following your admission into hospital, a case worker will be allocated to support the planning of your discharge. They will act as your single point of contact throughout the planning process. This person may change due to leave and other staff requirements. It may be necessary to involve other professionals in your discharge planning. Here are some of the professionals who may also be involved:

  • Specialist Nurse
  • Physiotherapist
  • Occupational Therapist
  • Dietitian
  • Speech & Language Therapist
  • Integrated Discharge Team
  • Social Worker
  • Community Nursing

A discharge assessment will determine whether you need more care after you leave hospital and where that care should come from. You will be fully involved in the assessment process. With your permission, family or carers will also be kept informed and given the opportunity to contribute.

The different types of discharge

1. Discharge home

In most cases, it will be appropriate for patients to be discharged home with no additional support or input required.

1a. Discharge home with informal support from voluntary organisations

Voluntary teams (such as the Red Cross) work with hospitals and provide a level of support that will help you get home. This may include transport, shopping, minor cleaning at home and anything else to ensure you are comfortable at home after discharge. As well as practical

help, they will support you in settling back at home, supporting you emotionally and highlighting organisations in the community where you can access additional support, which might range from services that help with social isolation to welfare advice.

1b. Discharge home with additional support from the NHS community teams: occupational therapists, physiotherapists, community nursing

This support will be organised by the discharge team, in discussion with you and those who care for you, and you will be told who is coming, how to contact them and who to contact if there is a problem.

1c. Discharge home with a care package

This will be identified following a full assessment with your social worker. In most cases, your ongoing care will be organised by the local authority. This is a chargeable service. A financial assessment will be requested, which will be required by your social worker. If you have complex health needs, you may be assessed and found eligible for Continuing Healthcare, which is provided by the NHS. You can choose not to have a financial assessment; however, this means that discharge will proceed on the basis of you self-funding care.

2. Discharge to somewhere other than your home

There may be several reasons why you would not be able to be discharged directly home from hospital. These are identified below:

  • Changes in your housing / home environment
  • Your home environment cannot meet your rehabilitation needs
  • Complex nursing needs
  • Your care and support needs can no longer be managed at home

In any eventuality, you will be discharged to the most appropriate accommodation, in some instances on a temporary basis such as:

  • Extra care sheltered accommodation
  • Community inpatient rehabilitation unit
  • Residential care home
  • Nursing home

We cannot always guarantee that the destination that you and your family request as a preference is available on discharge. Any changes or proposed suggestions will be discussed with you, your family and the discharge and clinical teams. We aim to ensure that every discharge is safe and completed in a timely way to prevent any potential risks whilst remaining in the hospital. However, sometimes unforeseen delays occur, or new options are provided at short notice. We aim to ensure you are provided with as much notice ahead of discharge as possible.

2a. NHS Continuing Healthcare

If you require a high level of health or care needs, the ward team involved in your care may refer you for an NHS Continuing Healthcare assessment. If you have been assessed as eligible for NHS Continuing Healthcare, a package of services to meet your care needs will be arranged and funded by the NHS. These services can be provided in your own home or in a care home, with or without nursing. If appropriate, this assessment should take place after you have left hospital and when you are in a care setting that is most appropriate for your care needs. This may be a temporary placement such as a nursing/residential care home. Every effort will be made to ensure that you are discharged to a temporary placement that is local to your family and friends. Due to availability of beds at the time of your discharge, it may not always be possible to guarantee that this temporary placement is within the location that you and your family would like. Longer-term nursing/residential care home placements will be based on all available local units across North West London.

2b. NHS-Funded Nursing Care

People with lower nursing needs who require a care home with nursing may be eligible for a weekly contribution towards registered nursing care. Your ward team can advise you on this. For more information, please ask for the leaflet: NHS Continuing Healthcare and NHS-funded Nursing Care – Public Information Booklet.

Funding

Care from NHS services is free at the point of access. However, discussions about the funding of your care arrangements for when you leave hospital will be had with you while you are in hospital, or with you or your nominated representative. Local councils are responsible for commissioning social care, and they each have their own charging policies. Your social worker will discuss what this means for you in detail. However, as a general guide, you will not be entitled to help with the cost of care from your local council if:

  • You have savings worth more than £23,250—this is called the upper capital limit (UCL) and will rise to £100,000 from October 2025
  • You own your own property (this only applies if you’re moving into a care home)

You can ask your council for a financial assessment (means test) to check if you qualify for any help with costs. More information about financial assessment can be found online at www.nhs.uk (Search Financial Assessment, Means Test). You can choose to pay for care yourself if you don’t want a financial assessment. However, this means that discharge will proceed on the basis of you self-funding care. You can:

  • Arrange and pay for care yourself without involving the council
  • Ask the council to arrange and pay for your care (the council will then bill you, but not all councils offer this service and they may charge a fee)

Medication

The hospital will aim to have your discharge medication ready on the day of estimated discharge.

Copy of letters

You will receive a copy of the letters sent to your GP relating to your hospital stay.

Therapy

If your hospital multi-disciplinary team decide that you require ongoing input from a physiotherapist or occupational therapist once home, they will ensure this is passed on to your local Therapy Team, who will support you to meet your needs and regain independence.

Therapy on discharge

If a therapy request is required immediately following discharge, you will receive a visit from a skilled and competent member of your local therapy team within 48 hours of discharge.

Community therapy

A member of the community therapy team will visit you for a period of up to six weeks. They will work with you on jointly agreed goals to continue your progress and maximise your independence at home, and, if appropriate, outside the home. The team can provide additional advice and support from local agencies and voluntary services to meet any ongoing needs you may have.

Being looked after—informal carers

An informal carer is anyone who cares, unpaid, for a friend or family member who, due to illness, disability, a mental health problem, or an addiction, cannot cope without their support. The role of a carer can encompass a multitude of activities including helping people to the toilet, assisting with washing, dressing or moving around the home, shopping, cleaning, cooking, laundering clothes, assisting with medication, managing money, and taking people to attend appointments. If you are helping someone because they are ill or disabled, then you are a carer. Carers UK has some very useful information about what to consider when coming out of hospital.

Discharge checklist

This checklist is for you, your designated hospital carer, and your family to ensure you have everything in place for your discharge. You should make sure that each of these questions is ticked off before you go home; if anything is not checked off, please ask the designated member of your care team to organise what needs to be done to ensure your safe discharge:

  • Have you made your relatives and carers aware of your estimated day of discharge?
  • If you had any cannulas inserted, were they all removed?
  • Have you fulfilled all requirements for you to be discharged?
  • Have you been to the toilet?
  • Have you had something to eat?
  • Have you planned where you are going ‘home’ to?
  • Do you have a key to get into your property?
  • Have you asked the ward staff to return any valuables you may have left in safe keeping?
  • Do you have all of your other personal belongings?
  • Have you made arrangements for your extra belongings to be taken home?
  • Do you have outdoor clothes for your journey home?
  • Have you changed into your personal clothes?
  • Do you need a Medical Certificate to cover your hospital stay?
  • Do you have all of your medication? If you normally receive your medication in a Nomad or Dossette box, it is important that you tell us before the day of discharge.
  • Have you arranged transport to take you home?

NHS North West London ICB, Version 1, March 2023