Hospital to Home Care | Hospital Discharge Care

Helping you return home from hospital

At Carefound Home Care we are able to offer a range of hospital discharge care options at short notice. This may involve hourly care and / or night care, or 24-hour live-in care should this be more appropriate. Our hospital to home care service is flexible and can often be provided on a short-term respite care basis to help a client with rehabilitation and recovery until they are able to cope with a less involved home care service or without the need for any further input at all.

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“As always your service is excellent and I am extremely satisfied with the services and the friendly staff (almost family)”

Miss F, Harrogate

What is hospital to home care?

Hospital to home care involves ensuring that an appropriate level of support is in place to help older people return home after a hospital stay. Typically, hospital discharge will only be able to take place if the elderly person returning home can do so safely with the right care in place and we are here to enable this. It is particularly important for people living with a cognitive impairment such as dementia to return home as soon as possible since the unfamiliar environment of a hospital can cause added confusion or disorientation.

Individuals who use are hospital to home care service are typically either:

Currently an in-patient in hospital seeking to return home immediately after being discharged
Due to be admitted to hospital and will require support after they have been discharged
In need of practical help or advice about returning home after leaving hospital
Already at home and in need of extra support following a recent stay in hospital

Whatever your needs may be we are here to provide a highly personalised care service tailored to your exact needs.

How is hospital to home care arranged?

We are able to provide support with hospital discharge at short notice on an emergency basis or following a scheduled hospital visit for planned operations such as hip replacement or major surgery. Our specialist home care management team will work closely with you, your family and other healthcare professionals involved to ensure you are able to enjoy a safe and prompt return to the comfort and familiarity of your own home. This may include working alongside the Discharge Team, occupational therapists, social services, doctors and District Nurses.

We are able to carry out a free assessment of your needs in the hospital and / or upon your return home which will be used to agree with you how you wish to be supported at home. This often involves help with recuperation, convalescence and rehabilitation for which our team of professional home carers are able to work closely with physiotherapists, occupational therapists, District Nurses and other healthcare professionals.

In addition to rehabilitation support, our home carers can help you with all other aspects of living in your own home including domestic help, companionship, medication help, personal care or specialist care for more complex conditions such as dementia care, Parkinson’s care or stroke care.

If you wish to speak with us regarding help with hospital discharge either for emergency care or for your future needs please do not hesitate to contact us today.

The hospital discharge process

Support Options

The type of support that you require upon hospital discharge will depend upon your needs and preferences, however the care plan agreed with you by the hospital staff may include:

Care and support from a private provider that you pay for either in your own home or a care home – this is likely to be the only option if you aren’t eligible for help from the local authority
Community care services from the local authority, such as reablement services – an assessment for these must be arranged if it seems that you may need them
NHS continuing healthcare – NHS funded care for somebody with a ‘primary health need’
NHS funded nursing care – provided by a registered nurse and only if you are in a care home
Intermediate care – this is short-term care that’s provided free of charge for people who no longer need to be in hospital but may need extra support to help them recover. It lasts for a maximum of six weeks and can be provided in someone’s home or in a residential setting
Other NHS services – such as rehabilitation or palliative care
Equipment – such as wheelchairs, specialist beds, or aids and adaptations for daily living

Home Care or Residential Care?

The decision to transition into a care home following a hospital stay or to return to the familiar surroundings of your own home should be based around the wishes of the patient and their individual needs. Many elderly people prefer to discharge into their own home with the support of a professional home care team where their care can be individually tailored to their specific needs, often involving specialist input from health professionals such as a District Nurse, physiotherapist or occupational therapist. This can be on an hourly care basis where carers will come at various times during the day, or a full-time live-in care basis to ensure support around the clock. There are many benefits to recovering in your own home including a smoother transition, familiarity, confidence, tailored activities and more personalised one-to-one care.

The Day of Discharge

On the day of discharge, the person co-ordinating the discharge should make sure that:

you (and a carer if you have one) have a copy of the care plan
transport is arranged to get you home
any carers will be available if needed
your GP is notified in writing
you have any medication or other supplies you’ll need
you’ve been trained how to use any equipment, aids or adaptations needed
you have appropriate clothes to wear
you have money and keys for your home

After hospital discharge your care will be monitored as set out in your care plan.

Planning for discharge from hospital

The discharge team is generally responsible for ensuring your safe discharge from hospital and the main point of contact will usually be the ‘discharge co-ordinator’ or ‘ward co-ordinator’. However, each hospital does have its own discharge policy so you should ensure you ask who will be responsible for coordinating your discharge.

If you are going into hospital for a planned procedure, deciding what will happen upon your discharge should take place before you go into hospital. If you are in hospital for an unplanned admission, it is important that discharge planning takes place from the day of your arrival.

You will usually be given an estimated discharge date within 24 to 48 hours of having been admitted, and should this change over time you should be kept updated by the healthcare staff in the hospital. As a patient in hospital you should not be discharged from hospital until:

you are medically fit (this can only be decided by the consultant or someone the consultant has said can make the decision on their behalf)
you have had an assessment to look at the support you need to be discharged safely
you have been given a written care plan that sets out the support you’ll get to meet your assessed needs
the support described in your care plan has been put in place and it’s safe for you to be discharged

There are generally two options for post-hospitalisation care – the patient may continue to heal and recover in a residential care home or, depending on a patient’s needs and desires, they may respond better to returning to the familiarity and comfort of their own home with specialist home care on-hand.

To determine if and what type of care you may need to be discharged from hospital a discharge assessment will be completed. This could be carried out by a team of health and social care professionals, especially if your needs are more complex, including (but not limited to) a hospital consultant, nursing staff, a social worker, a physiotherapist or an occupational therapist. You should be involved in this process and your views, and those of your family, listened to.

If you are to return to your own home with support from a home care provider you should inform them of this process so as they can be involved as required and make plans for your care. The discharge assessment may also include an assessor viewing you in your own home to understand how you will cope upon your return.

Following the completion of a discharge assessment by the health and social care professionals in hospital a care plan will then be drawn up, detailing the health and social care support for you. The care plan should include details of:

the treatment and support you will get when you’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 co-ordinating the care plan
who to contact if there’s an emergency or if things don’t work as they should
information about any charges that will need to be paid (if applicable)

Top tips for safe hospital discharge

Research and understand your options as early as possible – if you wish to return to your own home ensure that this is made clear to your discharge team
Keep your chosen care provider updated – ensuring that you provide sufficent warning and information enables them to plan and properly support a safe discharge and recovery

Obtain an updated list of your medications – these may have changed during your stay in hospital and it is important that you both have the correct medications upon discharge and your pharmacist, GP and / or care team can ensure your ongoing prescriptions are correctly provided

Home aids and equipment – you may have been provided with these which need to be available / installed and your care team may need to be trained in using them

Understand your physical limitations – be aware of what daily activities your hospital discharge team advises you are capable of and what is considered ‘high risk’ or ‘unsafe’

Make arrangements for your discharge day – consider how you will return home or if hospital transportation will be required. Also think about what you will wear and how you will access your house (e.g. do you have keys)