Social care support for patients leaving hospital

What happens after I leave hospital?

We understand that leaving hospital can sometimes feel uncertain. While everybody's circumstances are different, most people will move through the following stages as they recover and regain independence. 

The aim of the Home First approach is to support your recovery in the place that is right for you and avoid making long-term decisions about future care until your recovery has progressed and your needs can be properly understood.

Step 1: Planning your discharge

Before leaving hospital, staff will discuss your recovery, strengths, goals and available support with you.

Step 2: Returning home or to a temporary setting

Wherever possible, you will be supported to return home. If returning home is not immediately possible, a short-term stay in a residential or nursing setting may be arranged while you continue to recover. 

Step 3: Recovery and reablement

You may receive short-term support, reablement services, equipment or therapy to help you regain confidence and independence.

Step 4: Ongoing assessment

As you recover, professionals will work with you to understand your longer-term care and support needs. This helps ensure future decisions are based on your abilities once recovery has progressed.

Step 5: Longer-term support (if required)

Some people find they no longer need formal support once they have recovered. If ongoing support is needed, options will be discussed and agreed with you.

Several professionals may work together to support your discharge from hospital and your recovery afterwards. Depending on your circumstances, you may meet one or more of the following:

Social Workers

Social Workers help identify care and support needs, explore support available from family and community networks, provide advice and guidance, and coordinate social care support where required.

Nurses

Nurses support your clinical care and recovery and work with other professionals to ensure discharge arrangements are safe and appropriate.

Occupational Therapists

Occupational Therapists assess how you manage everyday activities and may recommend equipment, adaptations or support to help you remain independent and safe at home.

Physiotherapists

Physiotherapists support physical recovery, helping people improve mobility, strength, balance and confidence following illness or injury.

Discharge Coordinators

Discharge Coordinators help organise and coordinate arrangements to support a safe and timely discharge from hospital.

Reablement Workers

Reablement staff work alongside you to rebuild confidence, skills and independence following illness or a hospital admission.

Family, Friends and Carers

The people who know you best often play an important role in supporting your recovery and helping you achieve your goals.

If you appear to have care and support needs, a member of the Hospital Team, such as a Nurse, Discharge Coordinator, Therapist or Social Worker, will meet with you during your hospital stay. Together, we will explore your strengths, goals and support networks to identify the best way to support your return home.

We know that the period following illness or a hospital admission is often not the best time to make permanent decisions about future care arrangements. For this reason, the Home First approach focuses on supporting your recovery first and assessing your longer-term needs once you have had the opportunity to regain confidence, skills and independence.

Any new care and support arranged following discharge, whether this is support at home or a temporary stay in a residential or nursing setting, will usually be provided on a short-term basis while your longer-term needs are established.

Once you have recovered as much as possible and reached your potential, the temporary support will end and any ongoing arrangements will be discussed and agreed with you.

Family, Friends and Community Support

For many people, the most valuable support comes from those who know them best. As part of the discharge planning process, we will explore how family members, friends, neighbours and community networks may be able to support your recovery.

This might include:

• Help with shopping, meals or household tasks.
• Assistance with attending appointments.
• Emotional support and companionship.
• Support from community groups, voluntary organisations or local services.
• Technology and equipment that can help you remain independent.

We will always consider these options alongside any formal care and support services.

Reablement

Reablement is a short-term service designed to help you regain confidence, skills and independence following illness or a hospital stay.

Specialist support workers and therapists will work alongside you to help you achieve your own goals and do as much for yourself as possible. This may include support with:

• Personal care.
• Preparing meals.
• Mobility and moving around safely.
• Managing daily routines.
• Household activities.

The aim of reablement is not to do things for you, but to work with you to rebuild your independence and reduce the need for ongoing support wherever possible.

Care and support at home

If additional support is required, you may be able to return home with a personalised package of care.

Under the Home First approach, this support is usually temporary while we continue to understand your longer-term needs and how much independence you are able to regain.

As your recovery progresses, the amount of support you require may reduce, and some people find they no longer need formal care services at all.

If you already receive care at home, your support can be adjusted temporarily to help you during your recovery.

Direct Payments

Some people prefer to organise their own support through Direct Payments.

A Direct Payment provides funding that allows you greater flexibility and control over how your assessed care needs are met. It can also help make use of support arrangements that work best for you and your family.

In some circumstances, family members may be able to support you using a Direct Payment arrangement during the period when your longer-term needs are being assessed.

Residential and Nursing Care

Our aim is always to help people return home wherever it is safe and appropriate to do so.

Where a residential or nursing placement is needed following discharge, this will normally be considered a temporary arrangement to support your recovery and allow time for a fuller assessment of your long-term needs.

Moving into long-term residential or nursing care is a significant decision. We want to ensure that every opportunity has been given to maximise your independence and explore alternative options before any permanent decisions are made.

Family members, friends and carers often play a significant role in helping somebody recover following a hospital stay.
Where appropriate, and with the person's consent, we will involve carers and family members in discussions about discharge and recovery planning.

The support you provide may help with:

• Shopping and preparing meals.
• Transport and attending appointments.
• Emotional support and encouragement.
• Managing everyday tasks.
• Supporting recovery goals and independence.

We recognise the important contribution carers make and will consider the support available within a person's existing network alongside any formal care and support services.

A financial assessment will be completed to determine whether you are required to contribute towards the cost of any care and support services you receive.

The amount you may need to pay will depend on your individual financial circumstances, including your income and savings.

Your Social Worker will explain the assessment process and provide information about any charges that may apply.

Further information: Financial Assessment Booklet.

When can I leave hospital?

The hospital team will discharge you when you are medically well enough to leave hospital and it is safe for your recovery to continue elsewhere.

Will I receive support at home?

If you require additional support, arrangements may be made to help you return home safely. This could include support from family and friends, reablement services, care at home, equipment or other community support.

What is reablement?

Reablement is a short-term service that helps people regain skills, confidence and independence following illness or a hospital stay. The focus is on helping you do as much as possible for yourself.

Will I have to pay for care?

A financial assessment will be completed to determine whether you need to contribute towards the cost of social care services.

What if I already have a care package?

If you already receive care at home, your support arrangements can be reviewed and adjusted temporarily to help you during your recovery.

What if I cannot return home immediately?

Where returning home is not immediately possible, a temporary residential or nursing placement may be arranged while your recovery continues and your longer-term needs are assessed.

Who can I contact for further advice?

Please contact the Hospital Social Work Team: Hospital.Team@RBWM.gov.uk