Planning together: Leaving hospital when the time is right

Why am I leaving hospital?

The team caring for you have agreed that you no longer need hospital care and it is safe for you to return home to continue your recovery.

Why can’t I stay in hospital?

When you no longer need hospital care, it is better to continue your recovery out of hospital. Staying in hospital for longer than necessary may reduce your independence, result in you losing muscle strength pr expose you to infection.

Leaving hospital when you are ready is not only best for you but will free-up a bed for someone who is very unwell.

Our top priority is to ensure you are in the right place at the right time for the best recovery possible. The best place for you right now is at home where you can continue to recovery in a familiar environment.

What might I expect?

The team caring for you will discuss transport and other arrangements with you (and your carers, family and friends if you wish). If you need more care and support now than when you came into hospital assessments of your needs, as well as decisions about the provision of any long-term care and support will be made during this time. The team caring for you will be able to advise how long this period might be. After this time, you may be required to contribute towards the cost of your care and support if you need it.

Why can’t I complete my recovery where I am?

It is important that our hospitals and other care settings are ready to look after those people who need these settings. At the stage that you no longer clinically need these settings you will be safely discharged to a care setting more appropriate to your level of needs.

Studies have shown people lose muscle tone and become less independent while they are in bedded health care settings. Therefore, important to your long term health and independence that we minimise the time you are in these environments, and only use them when essential to your health care needs.

Will I have a choice of where I go next?

There are a number of community care bed providers across the city. This is a temporary placement, we will try to keep any preferences you have in mind, but we may not be able to offer you a choice of where this temporary placement is. If, following your period of recovery, you then need a longer term care home placement, you will then have a choice of your long term placement.

What happens if I need long term care?

Your long term care and support needs will be assessed while you are in this temporary nursing placement and as you continue to recover.

We will aim to complete the assessment within 28 days, however, we will work to ensure that this assessment is done as soon as possible. You will be regularly monitored by an allocated team.

Will I have to pay?

Your temporary placement is free while you require the NHS care in that setting or until your long-term care and support needs have been assessed by health and social care.

Once your social work assessment is complete and your needs determined, you may apply for financial assistance to see if you can get some help to pay your care home fees. A financial assessment will be undertaken to work out how much help you can get. Local Authority staff will support you with this. Care home fees apply at 28 days or the day after the social care assessment is completed if sooner.

How have my care and support needs been determined?

A case manager has been assigned to work with you and your carers to assess your ongoing care and support needs. The assessment of your needs has shown that we are unable to meet your care and support needs in your own home.

It is important that our hospitals and other care settings are ready to look after those people who need these settings. At the stage that you no longer clinically need these settings you will be safely discharged to a care setting more appropriate to your level of needs.

Will I have a choice of where I go?

The Social Work team will work with you to find an appropriate care home for your level of need, but of course you or your family can help in this process.
Once two care homes have been identified that meet your needs, we will expect you to choose one of these within 48 to 72 hours.

If a vacancy at your preferred care home is not available within 72 hours you will need to move to a temporary care home while you wait for your preferred care home to become available.

Will I have to pay?

Yes. You might qualify for means-tested assistance to help you pay your care home fees. A financial assessment will be undertaken by the Local Authority to determine whether you can get any help with paying your fees. They will also support you with questions relating to care home fees.

Care home fees apply from the day of admission to the care home. Should you choose to decline a financial assessment, you will remain responsible for the full cost of your care home fees.

Care home charges

If you do not qualify for financial assistance, you must contract privately for a care home of your choice and agree to pay the fees charged.

If you do qualify for financial assistance, the Local Authority will negotiate your care home fees. Usually, these fees will be at a lower rate than fees charged under a private contract.

If you are placed under a local authority contract but still want a more expensive care home, someone else must pay the difference in cost (for example, a family member or a friend). You are not allowed to pay the extra amount yourself.

We explain why you are being discharged from the rehab and recovery bed (R&R) and what you might expect after your discharge

Why am I being discharged from the rehab and recovery bed?

You are being discharged as your health team have agreed that you are now able to continue your recovery in another care setting out of the Rehab and Recovery Unit.

Why can’t I stay in the rehab and recovery bed?

The health system is extremely busy it is important that our hospitals are ready to look after those people who need hospital care and to free up hospital beds we need to be able to discharge as many people who need ongoing care from hospitals into the rehab and recovery beds.

It is our priority to ensure that you are discharged safely from the rehab and recovery bed to another care setting when appropriate. You are being discharged to a temporary placement for further care however, we will try to keep any preferences you have in mind, but we may not be able to offer you a choice of where this temporary placement is.

Who can I contact?

After you have been discharged, if you have any concerns or need to speak to someone about your care, you can contact the Adult Social Care team.

What can I expect?

Your discharge and transport arrangements will be discussed with you (and a family member or carer if you wish) and you will be discharged with the care and support you need to a care home.

You will not be able to remain in the rehab and recovery bed if you choose not to accept the care home placement that is being offered to you.

It is possible that you may be moved more than once after your discharge. This is because we will be trying to find the best place for your next stage of care. Your health team are here to answer any questions you might have.

Will I have to pay?

Your temporary placement is free until your long term care and support needs have been assessed.

Once your social work assessment is complete and your needs determined, you may apply for financial assistance to see if you can get some help to pay your care home fees. A financial assessment will be undertaken to work out how much help you can get. Local Authority staff will support you with this. Care home feed apply at 28 days or the day after the social care assessment is completed sooner.

We explain why it is important to start planning for you to leave a rehab and recovery bed.

Why are we starting to plan for me to leave the rehab and recovery bed?

Our top priority is to help you get better and support you to leave a rehab and recovery bed when the time is right. You will only leave a rehab and recovery bed when you no longer need inpatient care, and it is safe to do so. It is important that together, we start planning right
away to ensure you leave the rehab and recovery bed in a safe and timely manner.

In most cases, you will return home. You might need some additional care to help you in your recovery or practical support such as help with shopping. If you are a care home resident you will most likely return to your care home. If you require more complex support a member of the team will discuss this with you and a referral will be made to the appropriate service.

Going into Rehabilitation and Recovery unit if you get benefits

You must tell the office that pays your benefit as
soon as possible if you:

• Go into hospital or a Rehabilitation and Recovery Unit for one night or longer
• You must also tell them if you go into a care home and get benefits.
• A friend or relative can call for you.
• Your claim might be stopped or reduced if you do not report changes in your circumstances.

What might I expect?

Early conversations: Soon after you arrive at the rehab and recovery bed unit we will discuss and plan how you will be able to leave. We will involve your carers, family and friends in conversations if you would like them to be included.

Expected date of discharge: Soon after you arrive at the Rehab and Recovery Unit you will be given an ‘expected date of discharge’ (expected date you will leave the rehab and recovery bed) which will be reviewed during your stay.

What matters most to you to be considered: The team caring for you will ask ‘what matters most to you?’. They will ensure this is considered when planning for you to leave rehab and recovery bed.

Questions to ask during your rehab and recovery bed stay

• What is the main reason I am in a rehab and recovery bed for?
• What is going to happen to me today and tomorrow?
• What extra help might I need when I leave the rehab and recovery bed ?
• When will I be able to leave the rehab and recovery bed?