Essential guide to hospital discharge

We regularly hear about bed blocking in the news, but there is little reason for a patient to remain in hospital once they no longer require 24 hour medical attention.  Indeed, many people are actually safer at home, as long as they receive the right support.  It is particularly important for people with cognitive impairment (such as dementia) to return home as soon as possible, as the unfamiliar environment of the hospital often makes them feel disoriented and scared. So how does hospital discharge work?

One of the main reasons for hospitals not being able to discharge patients is the shortage of relevant staff involved in this process, particularly social workers, occupational therapists (OTs) and carers. Social workers assess the patient’s care package requirements, occupational therapists ensure the patient is returning to a safe home and carers help with a wide variety of task from personal care to domestic support and befriending. These steps are vital – if a patient is not safe and well at home they are highly likely to be admitted again. Unfortunately, when hospitals urgently need to free up beds patients can be sent home without the necessary assessments and services having been provided.

What is the Process of Discharging a Patient from Hospital?

When a patient no longer requires 24-hour medical attention and their medical condition can be managed outside of hospital environment, they are ready for discharge.

The hospital discharge nurse is the person in charge of coordinating the services required to ensure safe discharge from hospital. If the family and/or medical staff are concerned about the patient’s safety at home following the discharge, the discharge nurse should ensure the NHS social workers and OTs assess the patient and create a suitable discharge plan for the client. The discharge nurse has the responsibility of ensuring everything is in place before a patient is allowed to go home.

What is a Temporary Care Package? – NHS Social Workers

When a vulnerable person is ready to leave hospital, they sometimes need to have a care package to enable them to live safely at home again.  The NHS social worker is responsible for putting a temporary care package (4-6 weeks) in place.

If a patient was paying for their own care before going to hospital, they will need to reinstate this before they leave; it is the responsibility of the patient to do so and not the hospital or adult social services.

There are two types of temporary care packages offered by NHS Social Workers: Reablement and Non-reablement and patients will receive one or the other (not both).

1. Reablement Care Packages

The aim of reablement is to try to increase independence at home and thereby reduce the need for any future care. Reablement care packages are provided by trained carers with the support of rehabilitation OTs and physiotherapists who work for reablement companies; reablement companies are set up and funded by the Local Authority. The provision will only last for four to five weeks and it is free of charge.

People are not eligible for reablement if:

• They have received reablement in the past (after a previous hospital admission). In these cases, the hospital will have to provide a non-reablement care package until a social worker from the local authority’s adult social care team is able to assess for a personal budget.
• They have had carers at home before, either arranged privately or by the local authority.

2. Non-reablement Care Packages

If patients are not eligible for reablement and have not previously had carers, temporary carers will be arranged as a stop-gap measure to cover the time between leaving hospital and the assessment visit from the community social worker.

Basic Equipment & Minor Alterations  and working with NHS Occupational Therapists (OTs)

The discharge nurse at the hospital should make initial enquiries to ensure that patients are able to safely use their home facilities (bedroom, bathroom, kitchen and access etc.).  An OT assessment will be requested by the discharge nurse if a patient’s abilities have changed since they were admitted to hospital, or if the patient or family indicate that the environment at home will not be safe.

The OT assessment is undertaken by the NHS OT, whose main role is to provide rehabilitation to patients in hospital.  The OT tends to rely on the information provided by the patient and their family and will rarely visit the patient’s home.

NHS OTs are only permitted to prescribe minimal amounts of equipment and minor alterations, such as bed levers, basic grab rails, commodes, basic toilet seats and the installation of small steps.  They can also provide manual handling equipment.  There is no charge to the patient for this equipment regardless of their income or savings.

What happens following hospital discharge?

The NHS social worker should liaise with the community social worker (employed by the local authority Adult Social Care Team) and transfer the care to them.

The community social worker allocated to the case will make contact with the service user (they are no longer a patient) to arrange a home visit to discuss the care options open to them.

All permanent care packages are means tested; if you have any savings you will be expected to make a contribution towards paying for your carers.   If you have £23k or more in savings (per adult person) you will not receive any money from the local authority and you will have to privately fund your own care.

Permanent Care Packages – Community Social Workers

There are two different types of permanent care package: Personal Budgets and Managed Care Packages.

Personal Budgets

A personal budget is the money given directly to the service user from the local authority to enable them to pay for their own care.  It is the responsibility of the service user to decide who to employ as a carer (i.e. an individual or a care agency) and how to manage their carer. The local authority will review the case on a yearly basis to check that the money is being spent to support the needs of the individual and ensure their safety.

Managed Care Packages

If the service user does not have capacity to manage a personal budget and there is no family member to support them, the social worker can put a case forward to request that the care is managed by the local authority permanently. This means the local authority will source a care provider and review the care when needed.

Complex Equipment and Alterations to the Property – Community Housing OTs

If more complex alterations/ aids are needed the service user will be referred to the community housing OTs (employed by the Adult Social Care Team of the local authority).

Most community housing OTs have a long waiting list – in some cases up to 12 months or more.  It is wise to ring and check that the service user has been referred to them and to get an understanding of how long you will have to wait before you are seen

The community housing OT will conduct a thorough assessment with the client at their home Community housing OTs can provide more complex equipment from the council’s standard stock, this includes more complex bathing equipment like bath lifts, or equipment designed to help a person get out of bed, such as mattress variators. The standard stock equipment list is still pretty basic and limited, however all equipment is provided free of charge regardless of income.

If the risks to the service user cannot be reduced by the provision of equipment the OT will recommend modifications to the house to address and reduce those risks.  Modifications can sometimes be funded by the Disabled Facilities Grant (DFG) which is means tested.  See our helpful guides for more information

Wheelchairs

On discharge, the hospital will provide a wheelchair-bound patient with a basic transit wheelchair.  A pressure relief cushion should be requested by the patient or family members if there any skin integrity problem such as pressure sores. Pressure sores will be monitored by the District Nurse once the patient is back at home (see below for more information on District Nurses).

If the patient can walk, even if only for very short distances, it is unlikely the hospital will provide a wheelchair.  However, this does not mean you need to buy one – the local NHS wheelchair service will loan wheelchairs and deliver to a home address free of charge.  To get request one, you will need to ask GP to refer you.

Other Health Professionals

Discharge Nurse

As outlined above, the hospital discharge nurse is responsible for asking the NHS social worker to set up reablement and/or a temporary care package, and the NHS OT to provide basic equipment and alterations.

The discharge nurse is additionally responsible for:

• Providing the patient with a letter for the GP, which should detail the treatment received and medication prescribed (if this information has not already been sent automatically).
• Ensuring the patient has enough medication to last them at least a couple of days at home.
• Providing the patient with a limited supply of medical devices before they are discharged, such as stoma bag and pads. They will also inform the GP of the medical devices needed by the patient so that the service can be continued when they are back in the community.
• Referring patients to the community district nurse if the patient has on-going nursing needs.
• Referring patients to incontinence nurse if the patient has incontinent problems and requires pads on regularly basis. These should be provided free of charge once the service is arranged within the community.

District Nurses

District nurses visit patients at their home and provide nursing services in the community, such as changing dressings, arranging the delivery of ileostomy bags and giving injections (if the patient is unable to inject themselves).

Incontinence Nurse

Incontinence nurses work as part of the community. They will assess and try to address any health issues that are related to incontinency.  They also can provide pads free of charge for people who are permanently incontinent.

Community Matrons

Community matrons are highly experienced senior nurses, who work closely with patients in the community to provide, plan and organise the intervention from medical professionals. They mainly work with those with a serious long term or complex range of conditions and act on behalf of the GP in many cases.

Physiotherapists

When a patient is discharged and still has physiotherapy needs the physiotherapist from the hospital will refer them to the community physiotherapist.  Beware: the waiting list can be quite long and they are very limited in the number of sessions they provide.

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