Hospital Discharge Fact Sheet

Before leaving hospital

Do not be afraid to ask questions. You should understand what is happening after discharge, not simply when the person is leaving.

Things to check before you leave.

• What was the reason for the hospital admission?
• Is the condition stable enough for the person to leave hospital safely?
• Has anything changed since admission that will affect daily life at home?
• Has mobility changed, and can the person safely get in and out of bed and chairs?
• Can they manage stairs, washing, dressing, and using the toilet?
• Can they make food and drinks independently, or will they need help?
• Is there increased confusion, memory difficulty, or a change in behaviour?
• Has a discharge assessment found any need for extra care?
• What care or support is needed at home, when will it start, and who is arranging?
• Who is the home-care provider that has been informed that the person is returning home on xx date?
• Is equipment needed, and will it be in place when the person arrives home?
• Have medicines changed, and do you have the medicines needed at once after discharge?
• Do you know what each medicine is for and whether any have been stopped by the Dr?
• Have medication changes been communicated to the GP?
• Are follow-up appointments needed?
• Who should we contact if the person becomes unwell or recovery does not go to plan?
• Do you have the discharge information or care plan where applicable?
• Is transport home arranged and is the home warm, accessible, and stocked with essentials?
• Does someone need to stay with or regularly check on the person during the first few days?

What happens to benefits while you are in hospital?

A hospital admission can affect some benefits, particularly disability-related benefits. Do not assume the Department for Work and Pensions (DWP) will automatically know about the hospital stay.

GOV.UK recommends that the organisation paying the benefit should be told if someone goes into hospital or a rehabilitation centre for one night or longer. More than one organisation may need to be notified if several benefits are being received.

They may ask for:

• The date the person entered hospital.
• The date they left hospital.
• The hospital and ward.
• Details of any transfers between hospitals.
• Other hospital stays within the previous 28 days.
• What address the person was discharged to and by who.

Attendance Allowance, PIP and DLA

Attendance Allowance, Personal Independence Payment and Disability Living Allowance can be affected by longer NHS-funded hospital stays. The 28-day point is particularly important, and separate hospital stays close together can sometimes be linked when calculating the period. Check the person's individual circumstances with the DWP rather than stopping a benefit yourself.

Pension Credit

Pension Credit does not necessarily stop simply because someone is in hospital. However, added amounts within Pension Credit can be affected if a disability benefit changes or stops.

State Pension

A hospital stay does not normally stop someone receiving their State Pension.

Carer's benefits

If someone receives a benefit because they care for the person who has gone into hospital, their entitlement may also be affected depending on the length of the hospital stay and the benefits being received.

What if you think someone is being discharged too soon?

A person does not necessarily need to have fully recovered before leaving an acute hospital. Current discharge arrangements may involve recovery and assessment taking place at home or in another community setting once acute hospital treatment is no longer needed.

However, discharge should still be planned around the person's needs and right support. If you are worried, be specific about why.

Ask to speak to the nurse in charge, the clinical team, the discharge coordinator/team, occupational therapy or physiotherapy where relevant, and the hospital social worker where social-care needs are involved.

Explain what the person could manage before admission, what they can manage now and what help will realistically be available at home. Do not say that family members can provide care unless they genuinely can.

Questions to ask:

• What assessment has been made of their ability to manage safely?
• What has changed since admission?
• What help will be provided when they leave and when will it start?
• What happens during the first night?
• What happens if the care package does not work?
• Who do we contact for care arranged on homecoming?
• Has cognition or confusion been considered?
• Has mobility been assessed?
• Have carers' circumstances been considered?
• Would rehabilitation or enablement be right?
• Would a temporary recovery or assessment placement be safer than going straight home?

If you are unhappy about how a discharge has been managed, raise the issue with the staff arranging the discharge. In England, the hospital's Patient Advice and Liaison Service (PALS) can also provide support.

Home from hospital — help that may be available

Some people need little support after leaving hospital. Others need help to rebuild confidence and independence.

Reablement or intermediate care

This is short-term support designed to help someone recover and become as independent as possible. Depending on need, it may include:

• Help with washing and dressing.
• Practising preparing meals.
• Mobility and walking.
• Managing stairs.
• Physiotherapy.
• Occupational therapy.
• Nursing support.
• Equipment or adaptations.
• Rebuilding confidence with everyday tasks.

In England, eligible intermediate care is provided free for the period it is needed, commonly for a maximum of six weeks or less. Not everyone will qualify and arrangements vary locally.

Community health support

Depending on needs, support might involve:

• Community nurses.
• Physiotherapists.
• Occupational therapists.
• Or other NHS community teams.

Adult Social Care

If longer-term care is needed, the local authority can arrange a care needs assessment. This may lead to home care, help with personal care, day services, equipment and adaptations, supported living or residential care. A separate financial assessment may help to decide whether the local authority contributes towards longer-term social-care costs.

Support for unpaid carers

A family member or friend who regularly provides unpaid care can ask the local authority for a Carer's Assessment to look at their own support needs.

Moving into respite or temporary care

Going directly home is not always the right next step. A few people may benefit from a temporary stay in a community hospital, rehabilitation setting or care home while they recover or while longer-term needs are assessed.

This is different from making an immediate decision that someone should move permanently into a care home. A temporary stay can provide time to understand recovery, mobility, personal-care needs, cognition, medication needs and whether returning home is realistic.

Before agreeing to respite or temporary care, ask:

• Is this placement temporary?
• What is the purpose of the placement?
• Who arranged it?
• Who is funding it?
• How long is the placement expected to last?
• What rehabilitation or support will be provided?
• When will the person's needs be reviewed and who will carry out that review?
• Is returning home still the intended outcome?
• What happens if longer-term care becomes necessary?
• Will there be any charges?
• Could the placement affect benefits?
• Who should be contacted with questions or concerns?

Keep a hospital discharge folder

Hospital discharge can involve several organisations very quickly. Keep together:

• Discharge letter
• Current medication list
• Care plan
• Hospital and GP contact details
• Follow-up appointments
• Care agency details
• Social worker or discharge coordinator details
• Equipment information
• Benefit correspondence
• Care-home or respite information
• Important telephone numbers
• Notes of conversations and decisions

Where Golden Transitions can support

Hospital discharge can leave families trying to understand health care, social care, benefits, care providers and family responsibilities — often at the same time. Golden Transitions helps you make sense of the journey and work out what needs to happen next.