WhereIsTheCare wish to inform you of everything they have learnt and experienced regarding the discharge process from hospital of the vulnerable elderly, to support the effective and safe discharge for our loved ones and avoid re-admissions. These processes may change and be updated over time of course but it gives an idea of what should happen and what might be available.

Things may be happening that you haven’t been told about or don’t realise. Please don’t assume you will be told everything you need to know.

So many relatives tell us, that we just “assumed” this and that would happen. We did too.
Don’t assume, ask everything. The problem is you don’t sometimes know what to ask. Hope this helps.

We invite professionals who might be reading this to let us know any other information they feel might be added. We thank various contributors – Mid Essex Hospital Services NHS Trust, Basildon and Thurrock University Hospital Trust, ECL and others.

We will add additional information the end of this article as we learn new information or updates.

1. No-one should be sent home unsafe. Medically fit does not necessarily mean safe to go home.
2. Do not allow anyone to use jargon, abbreviations or terminology you don’t understand when talking to you, ask what does that stand for, what does that mean?
3. Make sure everyone knows that your loved one wishes you to be informed of treatments and conditions and care decisions and, if you do not have a Power of Attorney (you need to be seriously thinking about getting one), ask your loved one to write down their wishes to this effect and inform staff you have this or make sure the hospital know who is your loved one’s nominated person to speak to about their care and ask them to record it on their patient administration system. Check this has been done. (see our Article which is being written for us by the Mid Essex CCG regarding Information About Me forms to pre-empt such a future situation).
4. Keep a diary! Note down everything every day. Diagnoses, progression, assessments, who was present, outcomes, what people said, delays, obstructions, misstatements of facts, if intimidating or inappropriate pressure is put on you, healthcare appointments, relevant conversations with staff, phone calls, anything that doesn’t seem right, anything relevant from clinicians, doctor and all staff. (Read “Care To Be Different’s” website or buy their book “How to Get the NHS to Pay for Care”).
5. If you do not understand your loved one’s conditions or treatment ask for an appointment to speak with the consultant, in their absence – the ward manager/sister.
6. Refuse that your relative is discharged should you feel it is unsafe to do so until everything is in place that is needed to make them safe.
7. If your relative/cared for is likely to need further care and support when they go home, then the hospital staff will make a referral to the hospital social work team who are employed by your local council. Before they do this you should know, and they should ask for the patient’s consent.
8. If you think that they will need care and support at home, and the hospital team have not referred them, ask about this.
9. A community care or needs assessment must be carried out usually by social services, Adult Social Care Team, in the hospital before going home with input from hospital professionals such as an occupational therapist for example if additional support will be needed when your loved one leaves the hospital.
10. Social services have a legal duty to assess anyone who appears to be in need of support services. This is regardless of the person’s income and savings or whether the council thinks they will qualify for support.
11. If your relative needs ongoing full time care, they cannot be discharged from hospital until they’ve been properly assessed also for NHS Continuing Healthcare Funding, this process determines who is legally responsible for pay for the care, either the NHS or the local authority. It is not correct that NHS Continuing Healthcare funding is only available for people who are at the end of their life. It is a complex assessment and if your relative has significant health needs they may be entitled to this funding. This is the law, under the new Care Act 2014.
12. In emergency situations or when someone is in ‘terminal decline’ at the end of their life ask for an urgent Continuing Care assessment. Using the Fast Track Pathway Tool for NHS Continuing Healthcare, to quickly determine nursing care needs and to get NHS funding in place as quickly as possible. Some further information at www.caretobedifferent.co.uk.
13. There will be multi-disciplinary meetings (MDTs) happening to decide on your relative’s treatment and care and discharge in the hospital whether you realise or not. Ask about these, when they are, the outcomes and whether you can be involved as next of kin or cared for person’s representative.
14. You can ask to be involved in these meetings. You should be being informed about decisions being made.
15. There will be assessments going on – risk assessments for falls prevention, hydration and nutrition, pressure care, mental capacity and others – ask about these assessments.
16. Read the bedside notes so that you know what is happening. Food and fluid intake may be being logged for example including refusal of foods, if your relative needs pressure care management there should be chart to tell how often your relative is being moved and the equipment being used to prevent pressure sores. There may be body maps to show marks and any injuries on the body, medication charts etc. Read it all and ask questions.
17. If anyone has an unhelpful attitude or does not find out information for you, ask their name and ask the next rank up to them if necessary to speak with. On the ward it will ultimately be the sister (not junior sister), and then the Matron/Lead Nurse in charge of a number of wards, then Duty Manager and there is further levels above if you are still not getting the information you need, ask. If all fails go to PALS in the hospital, patient advice and liaison service with any concerns at the time and they should intervene and help. They are there for concerns whilst in the hospital not just complaints afterwards.
18. If you feel you need more help, you can always ask for advocacy or Hospital Carers Link Workers, within the hospital to help you through the system. Do not delay in asking for this, they can help act as an intermediary and that is what they are there for to help. For example, in Broomfield Hospital, Chelmsford, Action For Family Carers have an advocate/link worker employed within the hospital who can come to the ward and assist. As can the PALS Patient Advisory Liaison Service if there are concerns. They will usually have an office within the hospital, ask where this is.
19. Social services have an Adult Social Care Team/discharge team within hospitals. Ask for them if you are not sure your relative has been assessed or is going home with everything they need to keep them safe. A referral should already have been made to this team by the hospital for additional support and ongoing care needs.
20. They will visit your relative before discharge at the hospital- and the “responsible carer”, whoever that is, should be present.
21. There is a discharge team within hospitals who deal with simple discharges, this could be an Integrated Discharge Team, which is made up of a group of professionals from both Social Care and Health. There is also a Complex Discharge Team (CDT) if patient has complex needs. Ask the ward staff who is involved with your loved ones discharge and ask if you wish to speak with them. They include Discharge Coordinators, who organise ongoing care, family case conferences etc. Some Trusts go further, they have discharge advice helplines, or Journey Coordinators to help.
22. Care must be in place at home before discharge. Question what that that care looks like, what is needed, how that is going to happen.
23. Make sure you discuss the care plan with the hospital staff or social services. Think ahead, just because you may get care agency help referred or reablement it doesn’t mean your relative has been assessed properly, for example, if your relative can’t stand or weightbear very well and lives alone, they will probably need two carers at a time, or/and a hoist? An occupation therapist will have be involved to advise on how this will be done and equipment required.
24. If your relative cannot shift their weight, or turn over in bed, they will need a pressure care management plan, and the relevant equipment. Check if your relative has been able to turn themselves in hospital, and check your relative’s skin, if they have pressure sores question why, this is usually unnecessary, they will have had inadequate care where they are being discharged from and they will need a lot of extra care and district nursing on discharge.
25. Check things like continence and what you need for this – do continence pads need ordering, do you have a commode. Medication – have their been changes? Is the medication correct in the bags on discharge, do you have a list of the medications if not ask. Check everything about the current situation with your relative. Is Telecare equipment required? This is a call button in your loved ones home to summon help and with an increasing range of equipment available such as sensors.
26. Make sure you know about all ongoing referrals and make sure they have been made before you leave the hospital. If you require medical support following discharge home, this should be explained, and details of the services should be given to you before you are discharged. If not, ask.
27. There are matrons in the community called Community Matrons. Ask the hospital or your relative’s GP surgery about help for your relative when they come out of hospital. The Community Matron (your relative may already have one visiting them at home) can now be involved in the discharge process to make a smoother transition in care back into the community. More information can be found from your local Clinical Commissioning Group (CCG). We will be providing an article on this soon hopefully beginning of 2016.
28. If your loved one still needs nursing care but it is not acute, it might be appropriate for them to receive ongoing care in a community hospital (called Step-down care) until well enough and safe enough to be discharged. Ask about this.
29. DO NOT sign anything until you understand what you are signing. You may actually write on the form, if you do not agree with anything on it, and/or, what you understand the purpose of this form to be. More about forms see CareToBeDifferent website, wwwcaretobedifferent.co.uksign-hospital-discharge-forms/. Local organisations may be able to advise you also like Age UK Essex, a carers support group, Alzheimers Society etc.
30. A notice called “A Section 2 Notice” is issued from the hospital to social services to hand over the care on discharge to them. A ‘delayed discharge’ can be asked for and organised, the hospital issues a “Section 5 Notice” to inform social services about a delay.
31. Your relative should only be sent home or elsewhere if ongoing care is in place and they will be safe at their destination. We don’t just mean medical issues, we mean if there is no-one to greet them, to help them, if there house will be cold and empty and they have no food in the house etc etc. Sometimes relatives cannot get to the house in time or at that particular time to organise everything.
32. Do not allow discharge if reasonable advance warning has not been given to you the relative/responsible carer, to organise things at the elderly vulnerable person’s home or to arrange things for their return home. Discharge should not be jumped on you – “this afternoon”, “tomorrow morning”. You should be being included in the discharge planning process. Co-ordination and checking by the hospital that everything is in place should be happening 48 hours before discharge (NHS Institute for Innovation and Improvement). A day and time for your discharge home should be agreed in advance with the next of kin/carer involved.
33. Make sure you or your relative has a copy of the discharge summary, all these plans and assessments should be in it, treatment, future care needs. And a copy will be sent to the GP.
34. Make sure you check all medication, this is crucial. a. That you have what you should in the bag given to you on discharge, b. That this hasn’t been changed, and you or the carers haven’t been informed. You should be given a list of discharge medication.
35. Make sure all conditions are explained to you as the next of kin/responsible carer and you should receive written information and signposting about these diagnosed conditions before you leave the hospital to take home with you.
36. Elderly vulnerable people and their carers should be should be offered details of local voluntary sector organisations, other sources of information, practical and emotional support including information on accessing financial support and reablement services.
37. Once your relative is ready to be discharged from hospital, make sure that on the day of discharge they are being cared for properly and not left in the Discharge Lounge without care and attention. i.e. dressed properly, fed, and given drinks and had continence needs addressed.

What Kind of Support is There?

Getting extra support might help to boost the patient’s, your loved one’s recovery, re-build confidence, and so give a better chance of living safely at home again. Services called intermediate care (could be a community hospital, care home, reablement centre etc) or re-ablement services offer this type of support.

More information to what is mentioned below can be found on the ECC website www.livingessex.org as follows.
• Practical support with tasks such as shopping or cooking, or help with personal care tasks such as washing, dressing and going to the toilet
• Help to improve your practical skills and build your confidence on returning home. See “Regaining Your Independence”
• Provision of “equipment” or “gadget”s will make you safer and more independent in your home
• Planning for changes to your home which will make it more suitable to your changing needs. See our section on “Adapting Your Home”
• Planning for a move to alternative accommodation if this seems necessary. See our section on Finding “Somewhere to Live”
• Support in getting out and about once you get home
• Support for a relative or friend who is providing significant support to you. See: “Looking After Someone”
• Advice on money matters, and on making sure that you get all of the benefits to which you are entitled See: “Money and Legal”
• Go to “Requesting An Assessment” for more information on how the assessment process works, and on what to expect once the assessment is completed.
38. If there’s a possibility of your loved one going to live in a care home permanently after a stay in hospital, ask about intermediate care or reablement services. These services could allow them to to make as full a recovery as possible before making such a decision and help them to be independent enough to return to their own home (We know of someone who was admitted to a care home from hospital, relatives were not told about or offered reablement, WhereIsTheCare informed them, the relative received reablement in a reablement centre and was able to go home and stayed at home until they passed for a couple of years).
39. Intermediate care services can be offered free of charge for up to six weeks. Needs should be assessed, and then staff will agree some goals with you and your loved one that you and your loved one may hope to achieve within a specified time.
40. To help reach those goals, service may be offered from NHS staff such as physiotherapists or occupational therapists, along with social care support if needed. Services can be received in your loved one’s own home, in a care home, or at a day or community hospital.
41. Reablement. The aim is to help rebuild confidence, improve mobility and let your loved one see what they are capable of doing. To help them to maintain or regain the ability to live in their own home, this should be provided free of charge for up to six weeks.
42. This has similar aims to intermediate care, but focuses on helping to learn or re-learn skills necessary for daily living.
43. A care home place offered as intermediate care, temporary placement or interim placement, must meet the needs of the patient, these needs include family accessing them reasonably. Don’t agree to your loved being placed so far away to where you are living it is unreasonable for you to visit regularly. This is in detriment to the wellbeing of your relative. Ask for other options, don’t accept that there aren’t any. If need be make your own enquiries to find available places, and present to social services. Guidance is clear. If no suitable home is available to meet the individual’s care needs, with a vacancy at the rate the Council usually pays, the Council should increase its rate to secure a suitable placement. Placements are organised by the placement team of Adult Social Care.
44. When a period of intermediate care or re-ablement finishes, there will be an assessment to see whether any ongoing social care or NHS support is needed.
45. If you as a relative or friend who is providing some care, you may wish to ask for an assessment of their your own “caring” needs. The government see you as a carer if you are acting in a caring capacity and carers now have the same legal right to an assessment and to services as people with social care needs

Factsheets available.
FirstStop Advice is an independent, impartial and free service offering advice and information to older people, their families and carers about housing and care options for later life.

The Living Well website aims to help Essex people take care of their health and well-being, manage health conditions, and find information about support and services in the local area.

Various Factsheets available.


Information on procedures for discharge from hospital

previously Essex Cares

A provider working with local authorities and health partners to deliver services aimed at wellbeing, prevention and maximising independence, specialising in delivering flexible and responsive support within the home and within local communities across a range of services.

Essex Advocacy
0300 343 5736. If you needs someone to help speak on your behalf about treatment.