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Coming out of hospital

What is discharge planning?
What should a discharge plan include?
Who is involved in the discharge planning process?
What support and services can be provided?
What should I think about?
How do I pay?  What will it cost?
How do I complain?
Useful health information

Coming out of hospital can be a difficult experience, especially if you find that you are unable to cope as you did before.  You may wish to consider whether you need some extra care. There will be a team of people in the hospital who are responsible for helping you plan for your discharge.

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What is discharge planning?

Planning for your discharge from hospital should begin as early as possible in your stay in hospital.  In some cases this may even begin as soon as you are admitted.   This is called discharge planning and should identify what services and support you may need when you leave hospital.  By the time you are ready to leave hospital a clear discharge plan should be in place.  Discharge arrangements will vary depending on whether you are returning home or moving into a care home or other care setting (for information on moving into a care home from hospital please see our Caring for someone coming out of hospital page).

This discharge planning process should ensure that when you leave hospital you and with your permission (or when appropriate) your carer, know about the following:

  • Your medical condition

 

This should include information on treatment, medication and future medical appointments.  It should also include the names of your GP and consultant.

  • Services and support

 

This should include information on the services that have been agreed and that will be in place for you returning home, for example, home care, community nursing, day care services or equipment and adaptations to your home etc.

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What should a discharge plan include?

A hospital discharge plan ought to be prepared and should include:

  • The name of the member of staff at the hospital who is responsible for checking that you are discharged properly.
  • Arrangements for an Assessment of Your Care Needs if one is necessary.
  • Details of any support, help, equipment or adaptations which are to be set up at your home before discharge, and information about who is responsible for providing these.
  • Details of any contacts to be made to the community health services, such as GP, district nurse or social worker.

 

You can ask for a copy of your discharge plan.  So can your carer, or representative (with your permission).

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Who is involved in the discharge planning process?

Before you are discharged, you and your carer should be involved in decisions and choices about your care.  You should be interviewed in the ward, and a copy of the assessment given to you.  You may be, and can ask to be invited to discharge planning meetings. So may your carer, or other representative.

The following key people are usually involved in the discharge planning process:

Nurse in charge - is the main contact person while you are in hospital, overseeing the care provided and plans made for leaving hospital.

The Consultant - decides what medical care should be provided and decides when you are well enough to leave hospital.

Discharge coordinator - There should be someone responsible for coordinating your discharge available at the hospital that can assist in:

  • assessing and meeting the individual needs of carers;
  • involving carers in discharge planning; and
  • Highlighting and signposting carer organisations in the community.

 

Pharmacist - They provide the medication required for you and information on how and when it should be taken.

Other people who may be involved when requested and when necessary include:

  • Hospital social worker
  • Occupational therapist
  • Community psychiatric nurse
  • Physiotherapist
  • Speech and language therapist
  • Dietician
  • Incontinence Advisors
  • Chaplain

 

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What support and services can be provided?

There are a number of different types of assistance that you might need when you come out of hospital.  These can be organised (but not always paid for) by the NHS or Local Authority Social Work Departments, unless you prefer to do this for yourself or have it done by a carer or family member.   See also our page on direct payments.

In some cases, where someone has particularly complex care needs, the NHS will pay for all of the care.  This is called NHS Continuing Healthcare. 

  • Social Services should be able to provide services such as:

 

- Finding a care home
- Care at Home
- Equipment and Adaptations
- Meal Services
- Day Care
- Respite Care
- Transport Services

 

  • Some health services are provided from hospital, such as home visits from a physiotherapist or speech therapist. However most are provided by the community or local health services
  • A district nurse might visit to change dressings or give injections and may also be able to arrange equipment such as bedpans or a commode
  • A health visitor can offer advice and information on day-to-day problems
  • Your GP can arrange for specialist community health care

 

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What should I think about?

If you need to be cared for and supported at home for the first time or if your care and support needs have changed, it is important to make sure the right support and services are put in place.  Likewise, if you need temporary rehabilitation in a care home or move to a care home, it is very important to make sure you are fully involved and understand the choices that can and need to be made. For these reasons an Assessment of Your Care Needs is often initiated at a discharge planning meeting.

If services were already in place before you went into hospital, the main issues for discharge planning are to make sure that services and support will continue as before, or are changed to meet any new care needs. 

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How do I pay? What will it cost?

Most care services need to be paid for, How do I pay for care? provides information you should check about the following:

Financial Assessment
Free Personal and Nursing Care
Charging Policies
Self Directed Support
Pensions
Benefits
Help with Forms
Paying Care Home Fees
Money Advice

If you are aged 65 or over and have been in hospital for more than one day, you may be entitled to free home support for a limited period on leaving hospital if you need it and you were not receiving it before entering hospital.  However, if you were already receiving services before entering hospital, or your stay in hospital is part of ongoing care and treatment these four weeks may not be free.  If the hospital stay was long-term, care will need to be reassessed once you are discharged.

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How do I complain?

Whatever your situation it is important to know your rights and have access to advice.  Citizens Advice Scotland or Citizens Advice Direct (0844 848 9600 - advice line) can help you make a complaint.  The Health Rights Scotland leaflet explains how to complain using the NHSScotland complaints procedure.

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Useful health information

If you are looking for information on health conditions or to make sure, for example, that you are prepared for winter or look at useful common health questions then you can use NHS inform.  This is a new national health information service providing a coordinated approach and a single source of health information for the public in Scotland and can be accessed at http://www.nhsinform.co.uk or if you prefer to speak to somebody you can telephone 0800 22 44 88 (8am to 10pm) 

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last updated 14/04/2011