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Who will provide care & support when I am discharged from hospital?

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Every hospital has its own process and policy for discharging patients, which should be shared with you. Discharge planning often starts soon after you, or your family member, have been admitted to hospital. Although this can seem very quick, it is important to start considering options early to make sure everything is in place when you are discharged.

Any plans for discharge should be discussed fully with you, and your family members if you wish, and you should be given the appropriate options available so you can contribute to the decisions being made, particularly in relation to any ongoing care and rehabilitation requirements.

If, when you leave the hospital, you are assessed as needing no care or only a small amount of input, this is sometimes described as a minimal discharge. If you require more input for care and support, this will be referred to as a complex discharge.

Care assessments before discharge

If you are assessed as requiring input for care when you are discharged from hospital, this should be arranged for you before you leave. This can include:

  • Home help (assistance with mobilising around home, washing and dressing, and meal preparation)
  • Visits from a district nurse
  • Any aids and equipment you may need to increase safety and mobility

Whilst you are still in the hospital, someone from your treating team should contact social services so a discharge assessment for care can be undertaken if required. This assessment may take place in the hospital or at your home to assess how appropriate it is for your ongoing needs.

From this assessment, a care plan will be provided, which you should be involved in and agree to. This plan should include:

  • Information about ongoing treatment and support, including how often this is needed and when it will be provided.
  • Details about who will be providing this, along with relevant contact details.
  • How this support and treatment will be reviewed and monitored for your needs.
  • Contact details if your support is not working or going to plan, and what to do in an emergency.
  • Information regarding any charges which may be incurred (where applicable).

A letter containing details of your treatment in hospital and care needs should also be given to you for your GP, which is often provided at the time of discharge.

Care when you get home from hospital

There are two types of care when you get home from hospital; temporary care and ongoing care

Intermediate care, reablement and aftercare

If your assessment and care plan indicates you will only need care for a short amount of time to help you to recover, you will receive short-term temporary care called intermediate care, reablement or aftercare.

This care, which can include rehabilitation therapy as required, is available free of charge for up to six weeks but is often only required for around one to two weeks. If you require care for longer than six weeks, other options will be considered, and you may be asked to fund this as it is means tested.

If you are assessed as requiring temporary care, it should be arranged for you by your treating team before you are discharged from the hospital. This should be arranged before you go home, as the hospital will may not be able to provide as much help to you with this once you leave. If in the rare circumstance you have been discharged without any care in place, you should contact social services.

This care and rehabilitation aims to help you to get back to normal life and regain your independence.

This care will be provided by a variety of people, including:

  • Nurses
  • Doctors
  • Carers
  • Occupational Therapists
  • Physiotherapists
  • Social workers

They can help you to work towards regaining activities such as getting dressed, making a meal, balance, mobility and assistance with stairs. An assessment will be carried out to look at the activities you can and can’t undertake independently. You will discuss this and agree on what you can do and set out a plan to cover things you are unable to do independently.

Ongoing care

After your temporary care ends, the team will discuss your ongoing needs with you and look at further options for care and support. They will review:

  • What other ongoing care you need.
  • Whether another referral is needed and how you can do this.
  • Information in case something goes wrong.
  • Further details about other aids and equipment you might need.

If you require any further support, a full care and support plan will be undertaken. For a care and support plan to be put in place, you need to ask for an assessment from social services through your local authority.

The outcome of this assessment will then detail your care and support plan, which should include:

  • The things that are important to you.
  • Activities you can do.
  • Any equipment or care you need.
  • Feedback from your family and friends.
  • Contact details for someone if you have any questions.
  • How much funding your local authority will provide for your care and what care you an receive from them.
  • How and when this care will happen.

Regular reviews of your care and needs will be undertaken. These reviews will usually take place within the first few months after your care has started and yearly after that.

If you have any concerns about the care you are receiving, you should contact social services to address these.

There are different options for funding ongoing care and support once someone has been discharged from hospital. You can find out more by reading our blogs ‘How much care can I get on the NHS?’ and ‘Do social services provide care following a brain injury?

How CFG Law can help with your ongoing care

If you or a loved one has suffered a serious, life-changing injury, you need to know you’re not alone and you can get the support you need.

Not only can CFG Law help to provide you with legal advice, but we also pull together with you and your family to provide you with financial, physical and emotional support to ultimately help you to achieve your best outcome and lead a fulfilled life.

As part of our support service, we provide an emergency fund for eligible clients that can be used to pay for care, travel expenses for hospital visits, rehabilitation, counselling, purchasing specialist aids and equipment and help with other immediate care and support needs.

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