Coming home from hospital: arranging care for a safe discharge

Hospital discharge is when most families first come into contact with home care, and it is nearly always at speed. The ward wants the bed, the person wants to go home, and someone has to work out how they will manage when they get there. This article explains how discharge works in England now, what to ask, and how to get support in place so that the first week at home is not the week that sends them back.

How discharge works

Most hospitals in England use a model called discharge to assess. The idea is that the person goes home as soon as they are medically fit, and the detailed assessment of their longer term needs happens at home rather than on the ward. Short term support may be provided for up to six weeks while that happens, often free of charge, and then longer term arrangements are agreed.

In practice this means things move quickly and the family often has to make decisions within a day or two. The discharge team, sometimes called the integrated discharge team or the transfer of care hub, coordinates it. Ask who your named contact is on day one.

Questions to ask the ward

Is the person medically fit for discharge, and what date is being planned? What support will be in place when they get home, who is providing it and for how long? Has a needs assessment been requested from the council? Is reablement being offered? Has anyone considered NHS Continuing Healthcare? What equipment is needed at home and who is delivering it? What medication changes have been made and who explains them? Who do we ring if something goes wrong at 8pm on the first night?

Write the answers down. Discharge involves several teams and the family is often the only thread running through all of them.

Getting the house ready

Before the person comes home, check the basics. Can they get from the bed to the toilet? Is there a bed downstairs if the stairs are now a problem? Are the rugs that catch a walking frame put away? Is there food in the fridge and are the heating and hot water on? Is the key safe fitted if carers will be coming in? Small things, but the first fall at home often happens in the first 48 hours, and usually on the way to the bathroom.

Where a home care provider fits

If the hospital or council are providing short term support, a private provider can top it up, cover the gaps such as evenings and weekends, or take over when the free period ends. If nothing is being provided, or the person does not qualify, a provider can put care in place quickly. We can assess on the ward, visit the house before discharge to check it is ready, and have carers there on the first day. That first week is often heavier than the weeks after, with more visits, and then it eases as the person recovers.

The first two weeks

Expect the person to be more tired and less steady than they were before admission, even if the hospital stay was short. Expect medication to have changed and to need explaining twice. Expect at least one wobble of confidence. Plan visits for the times that carry most risk: getting up, washing, meals, going to bed. Then review after a fortnight and scale back to what is really needed.

Frequently asked questions

How quickly can care start?

For a hospital discharge, usually within a couple of days, sometimes the next day. Tell us the planned discharge date as early as you can and we will work to it.

Do we have to accept the provider the hospital suggests?

No. You can choose your own provider, and if you are paying privately the choice is entirely yours. If the council is funding the care, ask about a direct payment so that you can still choose.

What is reablement?

Short term support, usually up to six weeks, aimed at helping someone regain skills and confidence after illness or a hospital stay. It is provided or arranged by the council and is often free. Ask the discharge team whether the person is eligible.

Can you provide live in care for the first few weeks?

Yes. Short term live in care after discharge is common, particularly after a fall, a stroke or an operation, and it can step down to visits as the person recovers.

Someone coming home soon? Ring us on 0118 391 3542 and we will move quickly. Or book a meeting and tell us the discharge date in the notes.

Questions about care?

Our team can talk you through costs, funding and what might be available for your family. Call 0118 391 3542, it's free, and there's no pressure.