A Smooth Guide to Discharge Planning

It’s great news finding out that your loved one is ready to come home from hospital. After all, staying in hospital can be an unsettling and stressful experience for everyone involved. By being prepared and making the necessary arrangements, you can ensure their care needs are still being met once they have left the hospital.

SuperCarers, an online care company, have put together a guide for families and caregivers on how to ensure your loved one’s hospital discharge goes smoothly.

Your loved one may benefit from continued care upon discharge to ease their transition home and ensure they continue to recover. It’s important to be aware of the discharge process before your loved one leaves hospital to ensure that it’s as smooth as possible and that they get the care they need.

When should your loved one be discharged?

Your loved one has the right to discharge themselves from hospital at any time but it should always still be done under the guidance of their medical team to make sure that they do this when they are ready. Your loved one’s care team should draw up a treatment plan, including their discharge within 24-hours of your loved one’s admission; both you and your loved one should be involved in deciding this plan.

Your loved one should only be discharged if they meet the requirements dictated by the NHS here.

Planning discharge

Planning for discharge should usually occur right away as soon as you are admitted to hospital. This includes things like post-hospital care that may be provided by family and friends or a private care organisation like SuperCarers. You and your loved one should be kept up to date with any changes in your discharge date.

The NHS also notes that if you have limited capacity to make your own decisions that the Mental Health Act will apply. If this is the case, you and your loved one may consider enacting a power of attorney before you’re admitted to hospital.

Who manages the hospital discharge?

Each hospital will have its own discharge policy and arrangements. You should be able to get a copy from the ward manager or the hospital’s Patient Advice and Liaison Service (PALS). Discharge is usually coordinated by a key worker, a healthcare professional, often a nurse, who is assigned to your loved one and will be their main contact and source of support during their stay in hospital.
Depending on their condition, your loved one may need ongoing care from different healthcare professionals and services. If this is the case, they may be assigned a reablement team. This may include the following:

• Liaison nurse
• Nurse discharge coordinator
• Assessment officer

Discharge plan

Your loved one’s key worker and other healthcare professionals looking after them will make their discharge plan. They will conduct a discharge assessment of your loved one’s situation and find out what support they need when they return home. If you are the caregiver, you may need to help with the assessment by answering some questions to give some insight into their needs.
They may ask your loved one the following questions:

• Can you get up and down steps and stairs?
• How do you manage with personal care, such as bathing and washing?
• Can you prepare your own meals?
• Do you need financial support?
• Can you manage your medication?

The discharge plans can take several days to plan, especially if a number of different services need to be arranged.

Minimal and complex discharge

If the assessment determines your loved one as needing little or no care upon leaving hospital this is called a minimal discharge. If, however, the assessment determines that you need more specialised care after leaving the hospital, the discharge procedure is referred to as a complex discharge.

Discharge care plans

Complex discharge requires a care plan detailing your loved one’s health and social care needs. Your loved one will also receive a letter for their GP, detailing information about their treatment and future needs. The NHS states that a care plan should include details of the following:

• The treatment and support you’ll get when you’re discharged
• Who will be responsible for providing support, and how to contact them
• When, and how often, support will be provided
• How the support will be monitored and reviewed
• The name of the person coordinating the care plan
• Who to contact if there’s an emergency or things don’t work as they should
• Information about any charges that will need to be paid (if applicable)
• Information about any charges that will need to be paid (if applicable)

Care plans can include various types of support depending on your loved one’s needs. The support they receive may include:

• Intermediate care
• Community care services, such as reablement services
• NHS continuing healthcare
• NHS funded nursing care
• Specialist equipment, such as wheelchairs and aids and adaptations for daily living
• Support from voluntary agencies
• Care and support paid for privately

Carer’s involvement in discharge planning

If your loved one is in hospital awaiting discharge, you should never be put under pressure to take on a caring role or to accept more responsibilities than you already have. You should always be given enough time to consider whether you feel able to accept further responsibilities and you may request extra support whilst you make your decision.

If you decide to provide care for your loved one, you’re entitled to a free carer’s assessment from your local authority. This will determine what support you are entitled to, to ensure that you receive the help you deserve in your role as a carer.

What to expect on the day of discharge

The NHS stipulates that on the day of discharge, your loved one’s discharge coordinator should ensure the following:

• You and your loved one have a copy of the care plan
• Transport is arranged to get you home
• Any carers will be available if needed
• Your loved one’s GP is notified in writing
• You have any medication or other supplies you’ll need
• You’ve been trained how to use any equipment, aids or adaptations needed
• Your loved one has appropriate clothes to wear
• You loved one has their money and keys for their home

If your loved one is returning to care home, the care home should also be notified of the date and time of discharge, and they should also receive a copy of the care plan.

After discharge

Your loved one’s care should be monitored and reviewed routinely, as outlined in the care plan. The care plan should also tell you who to contact if you need extra support or face any problems with the care plan. If your loved one also receives community care services from a local authority, it should check that their care package is working well within two weeks of discharge. If your loved one lives alone, this should occur within the first few days of discharge. Following this, your loved one’s care plan should be reviewed at least annually.

SuperCarers matches families with highly experienced and trained carers to provide personalised care for your loved one based around practical, emotional, and physical support.