Good Care Group | Care after hospital discharge

Care after hospital discharge

As we get older many people may end up having a stay in hospital, whether for planned treatment like a hip or knee replacement or because of an emergency or an accident, like a fall. When the time has come to be discharged from hospital it is vital to your recovery that you have the right plan of care in place.

What is hospital discharge?

The process of leaving hospital is widely referred to as hospital discharge. Each hospital will have its own policy, which you should request as soon as you are able to after arrival in hospital so you can start planning your discharge with those responsible for your care.

Discharge planning for older patients

Most hospitals have a dedicated Hospital Discharge Planner whose responsibility is to ensure smooth transition from hospital back home ensuring the right on-going care package is in place if required. If you require care after hospital discharge, the provider you choose should be working closely with the discharge team at the hospital and other healthcare professionals involved in your care to ensure everything is in place for you when you leave.

Planning your or a loved one’s hospital discharge is key for effective, ongoing care in the community. Many patients who are discharged from hospital will have ongoing care needs that must be met in the community. This ongoing care comes in many forms, like support from an Occupational Therapist, daily support from carers to complete daily activities, or regular visits from district nurses to administer medication.

There is a wide variety of care available in the community, and it ideally should be planned in advance prior to returning home, to ensure that there is no gap in care between the discharge from hospital and returning home.

Discharge planning is the process where the hospital team considers what support might be required by the patient in the community, refers the patient to these services, and then liaises with these services to manage the patient’s discharge.

Patient information must be handed over from the hospital to the community team so an informed plan of care can be put into place.

Delays in hospital discharge

Frustratingly up and down the country there are countless delays to hospital discharge. This is when an individual is deemed medically fit to be discharged, but discharge cannot take place. Generally, this is because of delays in organising ongoing post discharge care. This can cause considerable distress and a long hospital stay for someone who is well enough to go home. It is important that you plan what you will need in terms of care after hospital discharge as soon as you can and put plans in place to speed up your discharge when the time comes.

Being discharged from hospital

Every individual hospital has its own discharge policy. You should be able to get a copy from the Ward Manager or the hospital’s Patient Advice and Liaison Service (PALS).

Once you are admitted to hospital, your treatment plan, including details for discharge or transfer, will be developed and discussed with you.

A discharge assessment will determine whether you need more care after you leave the hospital.

You should be fully involved in the assessment process. With your permission, family or carers will also be kept informed and given the opportunity to contribute.

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

When discharge is unsafe

Poor discharge planning can lead to poor patient outcomes and delayed discharge planning can cause patients to remain in hospital longer than necessary, when they could be more easily and comfortably cared for in their own home.

Patient discharge can become unsafe if a patient is discharged with no home care plan, or kept in hospital due to poor coordination across the different services required. Lack of integration and poor joint working between, for example, hospital and community health services can mean patients are discharged without the home support they need

COVID-19 and hospital discharge

Planning an efficient and safe discharge from hospital has added advantages during a pandemic. Due to the increased possibility of cross contamination within a hospital setting, risk of contracting a virus may be higher than if you were recovering in your own home.

Having an effective care plan in place prior to your hospital discharge could result in your hospital stay being shortened and your recovery continuing at home supported by the community teams.


Finding care after discharge from hospital

There are many options for care for the elderly after leaving hospital and returning home that you could consider:

Hourly care

If you just need some specific support during the day, for example getting up and dressed in the morning or having your meals prepared then hourly or visiting care could be considered. This is when a carer visits you at certain times during the day to provide care and support for everyday tasks.

Live-in care

Live-in care and support is when a Professional Carer comes to live with you to provide high-quality 24-hour care. This enables you to get support throughout the day and night, providing much-needed peace of mind and reassurance. They will be trained to support your ongoing health and well-being needs significantly improving the time it takes you to recover or rehabilitate, also avoiding the need to move into a care home.

Respite care and support

Respite care can be used for a minimum of two weeks for a short-term care arrangement to get you back on your feet following hospital discharge. Respite care can be offered in a residential care home or in your own home and can be used to give a family carer a break from caring for their loved one. If you have respite care at home it enables you to try home care, to see if it is right for you if your care needs may change in the future.

Convalescent care

Convalescent care is suitable for those who have received hospital treatment following surgery or an acute illness and need care and support to rest, recover and rehabilitate. Post-operative rehabilitation and convalescent care is focused on making you comfortable to enhance your recovery, whilst supporting you to rebuild life skills, confidence and independence.

Nurse-led care

If your hospital stay has resulted in you needing care of a complex condition, then nurse-led care can be provided at home. Nursing care is clinical care provided to an individual to support them through illness to improve their overall health and well-being. There are number of tasks a nurse will undertake, that with the right training, support and medical equipment can be delivered by a professional carer providing nursing care at home.

OT-led care

Occupational Therapy (OT) care at home can help people to overcome the challenges posed by permanent or temporary loss or lack of physical, sensory or communication function. An OT will assess you in hospital prior to discharge to assess follow up care after hospital discharge. They will put in place a comprehensive plan of care and advise on any equipment or home adaptations that will improve overall quality of life.

Why consider home care after hospital discharge?

Many people believe that when they need follow up care after hospital discharge, they need to receive this in a residential care home or a hospice for those requiring palliative care. It is widely recognised by the medical profession that receiving care at home has far reaching benefits to an individual’s recovery, overall health and well-being. Home care delivered by a trained and professional live-in carer, supported by clinical experts is a real alternative that allows a person to be cared for on a one-to-one basis in the comfort and familiarity of their own home with their family around them for support.

Choosing care after leaving hospital

You will need to understand from the healthcare professionals looking after you in hospital what level of ongoing care you will need, with an idea on how long care will be required to support your rehabilitation and recovery. Once you know what you require, then you will need to decide whether you want to receive care in the comfort of your own home, or move into a care home to get the care you need. There are many compelling benefits of live-in care, not least that you will have the peace of mind that your carer will be there for you around the clock providing all the support you need preventing unnecessary hospital re-admission. One-to-one care simply cannot be provided in a care home.

How can I arrange my own after hospital care?

If your financial resources are above the means tested threshold, the local authority does not necessarily have a duty to put a hospital dischrage care package in place for you. You are usually expected to arrange and meet the costs of care yourself. You are a ‘self-funder’.

As a self-funder, you can ask the local authority to arrange your home care package. They must agree to your request but can charge you an arrangement fee on top of the costs of services provided.

In all circumstances, you or your family are entitled to know the findings of your assessment and be given information and advice to help you understand your respite care needs, after your hospital discharge and the options open to you.

This includes details of:

  • the care system and how it works locally
  • types of care and support and choice of local care agencies/care homes
  • ways to pay for care and how to access independent financial advice to discuss ways of paying for care.

Due to the nature, complexity, intensity, or unpredictability of your needs, staff may want to consider your eligibility for NHS Continuing Healthcare (CHC).

CHC is a package of care funded solely by the NHS, if your need for care is primarily a health need. Staff must follow the ‘National Framework for NHS CHC and NHS-funded nursing care’ to decide eligibility. If eligible, you can receive CHC at home, in a care home, hospice or other suitable location.

If you are eligible for CHC, the whole cost of care and support services provided to meet your eligible needs are covered by the NHS. If your needs fall below this threshold, you have a right to a local authority care needs assessment, regardless of your financial situation.

Book your care after hospital discharge today

Why choose The Good Care Group?

We have been providing high quality, live-in care to families in England and Scotland for over 10 years. At the heart of our award-winning service is enabling people to live independently in their own home with an improved quality of life. Our approach to care at home means our clients can achieve improved health and well-being. For families they benefit from peace of mind and reassurance that their loved one is receiving the very best care and support.

A perfectly matched care team

A live-in care service usually involves two carers working a two-week rotation. They will be carefully matched working with you and your family. We make sure they are skilled and equipped to meet all your care and support needs. Our focus on matching means the care team chosen share common interests and backgrounds. We know this means life is enjoyable for everyone. Your care team really get to know you and your needs, which means you get consistency of care.

Expertly trained carers

All our professional carers are required to complete our leading training programme before they care for our clients. Our programme has been created with leading charities and clinical experts. It goes beyond mandatory requirements in the care sector. Carers are then equipped to provide high-quality care and support for those living with specialist conditions. Our carers never stop learning new skills to further enhance the care they provide.

Continuity of care

Unlike an agency we employ our carers. This means they are committed to us, as we are to them. Carers enjoy the security of being employed, which means they stay with us longer. Those who work for agencies move around more. For families this means that you get continuity and consistency of the same care team caring for your loved one. This means high-quality care can be achieved with improved outcomes and no disruption to your loved one’s life.

In-house clinical experts

We have a dedicated team of in-house clinical experts. This includes a specialist consultant nurse, who also provides Admiral Nurse services to those living with dementia. Our management team consists of nursing professionals. They guide our carers to provide safe and effective nurse-led care at home. We also have our own in-house Occupational Therapist (OT) who works closely with healthcare professionals and our care teams. Our OT provides guidance and advice that enables people to live well in their own home with any equipment they may need. These experts lead, monitor and support our care teams to deliver best practice nurse-led care at home.

Innovative care technology

Unlike any other live-in care provider, we have our own online care community. Families, healthcare professionals and carers can access up to date information about the care being provided. It enables more effective monitoring, which means issues can be responded to efficiently. For our families it provides a reassuring window into the care their loved one is receiving. Our carers also use the online community to share ideas and support each other. It provides a vital connection which is important when remote working. Carers will use the online community so their clients can enjoy time online. This includes video calls with family, so they feel connected. Clients can use it to shop online or browse the web.

Improving health outcomes

Every decision we make is driven by delivering improved health outcomes for our clients. Our digital technology allows us to predict risk and shape the care we provide. We measure health outcomes.

We want to know we are improving the quality of our clients’ lives every year.

Our health and well-being aim to reduce:

  • behaviours that may challenge
  • Antipsychotic drugs in dementia care
  • Falls in the home
  • Hospital admissions
  • Readmission to hospital
  • Urinary tract infections (UTIs)
  • Chest infections
  • Carer stress
  • They aim to promote:
  • Independence
  • Well-being
  • Excellent nutrition and hydration
  • Enjoyment in life

Highest service rating from care regulators in England and Scotland

Unlike introduction agencies we are fully regulated in England and Scotland. This means the care and support we provide is regularly inspected. We are the only dedicated live-in care provider in England to achieve an ‘Outstanding’ rating by the Care Quality Commission (CQC). We have achieved this rating in all five measures – safe, effective, caring, responsive and well-led. In Scotland, our service has been inspected by the Care Inspectorate (CI). It has achieved the highest rating of a 6 (Excellent) for quality of care and support and 5 (very good) for staffing, management and leadership. We know this provides families with peace of mind that their loved one is receiving the best possible care.

A fully managed service

Families benefit from our fully managed service delivered by care experts. This means you do not need to worry about supervising and managing the carer looking after your loved one. Our professional carers are supervised by an experienced care manager and supported by clinical experts. We provide this support 24 hours a day, 7 days a week. Your dedicated care manager will be on hand to support you, your loved one and our carer teams. We invest in our care management team to ensure they have enough time to give the support everyone needs. With our fully managed service, families do not have the burden of managing the care arrangement themselves. We know this means families can have peace of mind, whilst enjoying quality time with their loved one. They do not have to worry about the tasks of caring.

Local teams with national coverage

We operate throughout England and Scotland with a local approach to management of our teams near you. Each dedicated care manager local to you has only a small number of clients to support. This means they can provide higher levels of monitoring and support than other home care providers. It also means a highly personalised approach to care can be delivered.

Talk to us about your care needs

To talk about your care needs, contact one of our friendly advisors. Calls from landlines are free.

0203 728 7577

Enquiry form

Enquiry – Floating Button