Managing hospital discharge for elderly

If your elderly relative has been in hospital, it should be good news when they are ready to come home, but sometimes, managing their discharge from hospital can be a real worry. Can you ensure that they have the right level of care when they get home and what are the hospital’s obligations in this respect?

Hospitals must have a plan to help your elderly relative to go home safely from hospital. If you are unsure what these plans are, you must ask, as every hospital will follow different procedures. They should have a team co-ordinating the discharge and they may also involve a social worker.

Should your elderly relative be discharged?

A discharge should only be arranged when the patient is well enough to go home and the doctors are satisfied that this is the case, but also, it is imperative that the patient has sufficient care at home, so that they can manage and continue their recovery. If you or your elderly relative does not feel they should be discharged, you must discuss with the doctors and other medical staff. Similarly, I you do not believe that your elderly relative can manage at home, you must ensure you are happy with the arrangements the hospital are suggesting.

Often elderly people will try to discharge themselves, because they want to go home. The doctors should prevent this, but sometimes your relative can persuade the doctor that they are better than they are and that they can manage at home, just because they are desperate to leave hospital. You must work with the hospital staff to ensure they have the full picture. You and your relative should be involved and informed about all arrangements.

To be discharged, your older relative should be judged to be medically well enough, been assessed for care needed at home, been given a written care plan  detailing the support they will receive and that that support is ready for them when they leave.

Your elderly relative should never be discharged in the middle of the night, or without adequate arrangements for transport, but sadly, this does happen.

What is a discharge/care plan?

Discharge/care plans are usually arranged by a key worker, or discharge co-ordinator, who is a nurse or other healthcare professional. This person should be your elderly relative’s main point of contact during their stay in hospital. Following discharge, your older relative might require ongoing care from a various organisations and healthcare professionals. If they do, their key worker should manage the arrangements for when they go home.

In order to prepare an effective discharge plan, the key worker should check the following:

• Mobility, including managing stairs
• Ability to wash, dress and make food
• Whether help is required with these issues

Depending on the needs of the patient, their key worker will liaise with social workers, physiotherapists, occupational therapists, speech therapists, mental health nurses and dieticians.

The key worker should take time to make sure all adequate resources are in place before discharge takes place. A social worker may be called in to arrange at home care. If intermediate care is required, this can be arranged free of charge for six weeks, without the need for full assessment and regardless of savings and income.

If your older relative’s needs have changed significantly, they may need to be assessed for ongoing care support. You can find out more about these assessments here.

A discharge plan should include:

• Support and treatment needed on an on-going basis
• Who is responsible for providing care and their contact details, plus details of who is co-ordinating the overall plan
• When and how often the care will be provided
• How the care will be monitored and reviewed
• Emergency contacts
• Any relevant information about who is paying for which services

Some of the care services might include:

 A care plan could include:

• Community care services, following an assessment. Read more about assessments here
• NHS continuing healthcare, for those with very severe and complex healthcare needs. Read about Continuing Care here
• nursing careNHS funded , for those who need to be cared for in a nursing home
• Intermediate care, which is short-term care free of charge for a maximum of six weeks at home
• Palliative care. Read more here
• Special mobility equipment, such as wheelchairs, beds, or adaptations for daily living.
• Support from voluntary agencies. RVS provide a great home from hospital service
• Private care, if your elderly relative is no eligible for state support

What should happen on discharge day?

• You and your relative should have a copy of their care plan

• Transport should be arranged
• their carer should know they are coming home
• their GP should know they are being discharged
• they should be given the medicine and any other supplies they need
• they should know how to use any assisted technology or mobility aids as necessary
• they should have suitable clothes and shoes to wear
• they have keys and money

myageingparent.com has teamed up with Design for Independence Ltd, a private specialist housing occupational therapy company, to help your elderly relatives adapt their home to maintain their independence

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