Arranging care after a hospital discharge

Written by Zenya Smith03/02/23


Arrange care

This article was reviewed by a member of our in house clinical team Alexis Cable.

When your mum, dad, or anyone you care about is in hospital, certainties can be few and far between. From condition and outlook to even securing a day of discharge can change last minute. If you’re worried about an imminent discharge and are unsure how to get the right care in place, this article may help. 

Often the stresses and strains of having to visit, comfort, and make sure a loved one in the hospital is feeling safe and well can be a full-time activity in its own right. With all this going on, and when you think you’ve already got the right care solution in your sights, it can be frustrating when a change in circumstance suddenly throws everything off.

If this is the case, there are steps you can take to regain control and find the right care solution for your loved one, and peace of mind for yourself. 

Many older people are being kept in hospital longer than they need to be 

Unfortunately, it was estimated in November 2022 that one in three hospital beds was occupied by someone medically fit to leave the hospital. However, they were unable to do so because they didn't have the right care in place at home to safely support their recovery or ongoing health conditions. This has been fuelled by many large social care providers lacking the number of staff they need to provide care.

Getting their needs assessed

The majority of people can’t wait to get back home after a discharge from hospital. However, if they suddenly find themselves less mobile or steady on their feet, or more breathless or weaker than usual, they’ll likely need someone at home with them to keep them safe. This isn’t always possible if they live alone, or have a partner who has their own limiting health conditions. 

What will hospital staff do to prepare me for discharge?

UK hospitals have their own discharge teams, who manage safe transfers of care for those returning home from hospital. They’ll follow a procedure called ‘discharge to assess’ to review the level of care a person will need once they’ve left the hospital. While the policies around discharge can differ between hospitals, a discharge planner will usually only release a patient if the following discharge process has happened – 

  • A discharge assessment of their immediate needs has been completed 
  • A senior member of staff has “medically cleared” them. 
  • written short-term care plan has been created for those with specific or ongoing health needs. This will usually involve collaboration between the hospital and local community services 
  • The care plan has been implemented i.e the right level of care has been arranged, either privately, or through your local social services. This also includes making any required home adaptations, such as installing ramps or grab rails. 
home carer help after a hospital discharge

Can I get six weeks of free intermediate or reablement care?

Sometimes a person will only need temporary support after a hospital stay, while they regain their strength and get back on their feet.

In order to aid a timely discharge and allow people to recover in a more comfortable environment than a hospital ward, the NHS may offer a type of short-term care called intermediate or reablement care. It's an effective form of care that can reduce the risk of readmission, and offer more positive outcomes for people keen to get back to normality.

Intermediate care is usually provided in a person's own home. However, if a person's home isn't suitable or safe for care, they may be offered a short stay in an acute hospital or other community health service.

The type of reablement support a person receives depends on their individual care plan. It may be as simple as having regular visits from a carer to support with daily life - helping with personal care, cooking, and cleaning, for example. Meanwhile, other patients may need visits from a mix of clinical staff and social care staff, such as nurses, social workers, and occupational therapists - e.g a speech and language therapist.

NHS intermediate care is NHS funded - meaning it is free for the patient. Most people only end up needing support for a couple of weeks, however, you can receive up to six weeks of support for free. However, once the six weeks are up if further ongoing care is required this will need to be arranged and paid for either privately, or via a person's local authority. If you're likely to need further support a team should reach out to you during your recovery to review your long-term care needs. This will usually involve a Care needs assessment, which will be performed by your local authority. This is also why a thorough discharge assessment is so essential when leaving the hospital, as it ensures longer-term needs are recognised and planned for ahead of time.

Arranging the right care after hospital discharge  

As we’ve briefly mentioned above there is a lack of community services and residential care at the moment – the demand is simply outweighing the need. However, you’re well within your right to request a preference for a private home care provider, such as Elder, to help get your loved one home faster.

Whether temporary or longer term – it’s always worth voicing your preference for at-home care as early as possible. This will ensure additional steps – such as starting a care needs assessment and financial assessment into your eligibility for ongoing care funding can begin.

If your loved one has a life-changing medical condition, they may be entitled to have their full care costs covered via NHS Continuing Healthcare. Speak to the discharge team or ward consultant about beginning the application process. 

Home care or residential care? 

It can be difficult to know which type of care is best. Often a family’s first thought is a care home, as for a long time this has been the accepted ‘standard’ of elderly care for the vast majority. However, often home care can provide the same level of care as a care home, without the upheaval.

Live-in care involves an experienced carer moving into a person’s home, ensuring there’s someone on hand to provide personalised care around the clock. it provides a strong continuity of care as an individual is supported by just one, dedicated care professional. For those with a strong sense of independence, set routine, and the emotional pull of pets, it can help them to maintain their quality of life. 

One of the most common issues we deal with is that those working in the hospital are simply unaware that live-in exists as an option, or sometimes unaware of how our introductory agency model is treated by the NHS, the CQC, and local authorities.

That’s not to say care homes aren’t a good choice for elderly patients. In fact, some people are better suited to this type of care. Care home residents can benefit from on-site healthcare professionals, which can support the care of more complex conditions. Outside of the package of care, care homes offer a schedule of social activities and professional catering too. 

‘Home first’ with Lee Moran

The NHS is encouraging a ‘home first’ approach to support recovery in their own homes, whenever possible.Lee Moran, Home First Service Lead at Rotherham NHS Foundation Trust, has shared with us how the Home First system is working in his local area.

The Government's 'rapid discharge' fund

With hospitals unable to discharge many older patients, The Government announced a £200m fund in January 2023. This fund will allow the NHS to 'buy' thousands of extra beds in care homes and other inpatient hospital settings to improve patient flow out of hospitals. However, some social care experts are concerned that many people won't be suited to a care home environment. And, with staff shortages still a problem across the UK, there may not be enough care home staff available to look after these additional residents.

If you're worried, it's important to remember that, only you, your loved one, and your family will really know which care setting will be the right choice. Don't be afraid to voice your wishes. And, If you're feeling pressured into something you're not comfortable with during the decision-making process, it can help to speak to an independent advocate, from a dedicated organisation such as PoWher, or OPAAL.

How Elder can help:

1) Give us a call – we may be able to liaise with the hospital discharge planning team or your local social services to check the progress of any care needs assessment, and understand whether the support of an Elder-approved carer would be suitable. 

 2) If you’re new to the world of care, our care advisors can help you understand more about the different types of funding available. You can also try our free online funding calculator tool to find out whether it’s likely you’re going to be eligible.

3) If you’ve completed the full assessment process and are eligible for care funding, we can talk directly with your local authority or Clinical Commissioning Group on your behalf to look into arranging a personal health budget or direct payments. 

4) In some cases, our own clinical team can speak with the medical professionals who are helping your loved one out, to help ensure their needs have been accurately shared with Elder. 

Even if live-in care isn’t deemed to be the best solution, that’s ok, we can still speak to the NHS about the different options available and help find the best outcome for your family. In fact, we have trusted partnerships with a number of national nursing care and care home providers – and can put you in direct contact with a provider better suited to your requirements or preferences. 


What happens next?

  • Review your hospital care plan and keep it safe- once you’ve undertaken a care needs assessment, this will keep all your really important information in one place.
  • Make a list of questions – think what you’d like to ask the hosptial staff, your doctor, or your GP, and write it down in a list.
  • Think about transport – organise for someone to pick you and your loved one up from the hospital or check if the hospital can organise transport.
  • Ask your doctor or nurse to contact us – we find it’s often much simpler for everyone involved if your relative’s healthcare professional reaches out to us directly.
This article is for informational purposes only and not to be taken as medical advice. For medical advice, always consult your GP.

Learn more about arranging care

Take a look at more Elder guides on how to put your care plans into place

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