Support when you leave hospital

What will happen:

• You’ll be given an estimated leaving date within 24 to 48 hours of being admitted to hospital. 
• Your progress will be reviewed and if there’s likely to be a change to your leaving date a discharge co-ordinator or ward co-ordinator will keep you updated. 
• If you need support to return home; even if this is in the short term to regain your independence, an increase to your current care package, you need equipment to manage or you need a residential or nursing placement, a referral will be made to the hospital discharge team. 

Assessment, Referral, and Care Plan

Assessment

Before you leave hospital you will have an assessment which will look at your needs. If the assessment shows that you need extra support you might be visited by:

• A social worker
• A physiotherapist
• An occupational therapist
• A speech therapist
• A mental health nurse
• A dietician

You will be fully involved in the assessment process. Family carers will also be kept informed and involved but only with your permission.  

If you need help putting your views across, an independent advocate may be able to help. 

Care plan

Your care plan will be drawn up for you to leave hospital and with your permission, your family or representative will be given the full details: 

• Who is providing support and how to contact them? 

• The support you will get when you leave. 

• When and how often support will be provided. 

• How the support will be monitored and reviewed 

• Who to contact if there's an emergency or if things don’t work as they should. 

• Any charges that will need to be paid if this applies to you, this will be determined following a financial assessment. 

• Any equipment you require to go home. 

• Referrals to Home from Hospital will be made if appropriate.  

On the day you leave hospital

On the day you leave the hospital will make sure that: 

• Your GP is notified in writing. 

• Transport is arranged to get you home. 

• You have any medication or other supplies you’ll need. 

• You’ve been shown how to use any equipment, aids or adaptations needed. 

• You have appropriate clothes to wear. 

• You have money and keys for your home. 

In hospital you will be assessed by the social worker, if you  require to be discharged to a care home, once this has been arranged the discharge to the home will take place. If you are a private funder then the Independent Broker within the hospital discharge team can provide information (see below, under long term support.)  

Available support

This depends on your circumstances and might include:

Short term needs

• Health liaison team - provides information and advice to help people, carers and families with care and support and how to fund it.  

• NHS continuing healthcare - Visit the NHS website to find out if you are eligible for free care outside of hospital at home or in a residential setting. 

• NHS reablement - helps to get you home from hospital as quickly as possible and to maintain your independence. 

• Optalis START ( reablement team) service - helps to regain your independence  to manage your daily life  

• Age UK Home from hospital service - provides practical support as well as advice and reassurance about how to manage at home. 

Long term needs 

NHS Healthcare Services:

• NHS funded nursing care - if you are unable to return home

• NHS services on the Berkshire NHS Healthcare Foundation Trust website

Search the community directory:

Household aids, equipment and adaptations

Carers and home care services

Personal alarms and telecare services

Your care will be reviewed to ascertain if you continue to need it.   

This could be as early as the 2nd week or at the point when you are either able to manage on your own or long-term needs are identified. Reablement is up to 6 weeks and then if required your ongoing support will be arranged following an assessment, or   you will be passed information for you to set up your care if you are a private funder, via the Independent Broker.   

We will work within a Strength Based Approach. Please read our Strengths-Based Approach Leaflet (PDF document) for more information. 

Finding your own support

If you're arranging your own care and support you can find more support services in our community directory. Use our online tool to help you find care and support services:

Online tool to find support services

If you are over the financial threshold you will be expected to fund your care. We have an Independent Broker in the hospital discharge team, who can offer information and advice on care agencies, residential and nursing home placements. This service is free of charge and the hospital will refer to the hospital team for this and the independent broker will contact you to support.  

Carers involvement

If you're going to provide care for the person leaving hospital you can ask us for a carers assessment.