Hospital Discharge Information

• We will plan for an ‘estimated discharge date’ when you come into hospital, to make sure you return home as soon as you are medically ready.
• There potentially will be lots of different people involved in your care e.g. Doctors, Nurses, Therapists. Make sure you talk to them to understand what is happening, as they understand how important it is to get you home.
• The acute hospital team will plan for you to return to your usual home. The team will support you to return home as soon as you no longer need hospital care.
• It may be that you need more care, or further assessments in another setting. The acute hospital team will discuss this with you.
• Your discharge planning will cover anything that you might need, such as transport, equipment and any other areas of support and help.
• Each 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).
• You may want your family, friends, social networks or carers to be involved in your discharge planning. Please ask one of the hospital team to support you contact who you wish to be involved.
• The people who know you best, normally are the best people to support you on your return home, and you will recover far better in a community location.
• If you are unable to make your own decisions and do not have anyone to help you, we can arrange for an independent representative (patient advocate) to support you in discussions about your care.

We will always aim to get you home as early as possible on your day of discharge, rather than keep you in hospital for longer than necessary.

As discharges can often be arranged in a matter of hours, you and your relative, friend or carers will need to think about;

• How you will get home.
• How you will get in to your home, do you have your keys.
• Do you have suitable clothes and footwear to go home in.
• Is there food and will your home be warm for you.
• You may ask a friend or relative to stay with you or visit you regularly after you are. discharged, to help your recovery. If this is not possible, make sure you have plenty of food and essentials when you return home.
• If you have a medical condition, it may be that we will arrange your transport home by Hospital Transport.
• Hospital transport is only available if you meet strict medical guidelines. For example, you could be eligible for hospital transport if you need medical support during your journey and this means you cannot use regular transport.

• You may require more support in the first few weeks such as equipment or therapy and we will help arrange this.
• On the day of your discharge, you may be moved to a seating area or to our discharge lounge, where you will be looked after until you leave hospital.
• We want to get you home as early as possible, so you have time to settle in at home or in another community setting.
• You will be provided with up to 7 days of medication and one of our team will discuss how to take your medication and any possible side effects.
• If you have any questions, when you are at home please contact the ward, your local pharmacy or your GP for more information.
• Your GP will continue your care once you have been discharged from hospital. You may need to come back to hospital for a follow up appointment but this will be discussed with you before you leave.
• If you are unsure about anything in the days after leaving hospital you can contact the ward for advice. You can also contact your GP, or NHS 111. If you need urgent care, 111 can offer you access to the care you need.

This information lists useful advice for family and friends of people who are being supported by family or friends with day-to-day life. Support may be in the home or remotely (for example, by phone), and might include:

• Emotional support like helping someone manage anxiety or mental health.
• Housework like cooking, cleaning or other chores.
• Personal support like help moving around, washing, eating or getting dressed.
• Assistance with getting essential items like medicine or food.
• Help to manage money, paid care or other services.
• Check what your council or local authority can offer.
• Find their websites using the online postcode tool at www.gov.uk/find-local-council. Services may change during the pandemic.
• Read the government guidance for unpaid carers: More detailed advice on caring for friends or family during coronavirus is on GOV.UK.
• Register for extra support from NHS volunteers: Carers, as well as those they care for, can get a range of help including with shopping and other support by calling 0808 196 3646.

Get help from others with caring and everyday tasks

• Try not to do everything yourself. Speak to friends and family about what support the person needs and what others can do to help. Can they share any tasks?
• Go to the Carers UK and Carers Trust websites for information about support available. Carers UK also has an online forum where you can speak to other carers, and a free helpline, open Monday to Friday, 9am to 6pm on 0808 808 7777.
• If you’re employed, talk to your employer about managing work while caring. You may be able to arrange flexible working and many employers offer other ways of making things easier.
• If you’re at school, college or university, let them know you are caring for someone so they can help you manage your studies. Carers Trust has lots of helpful advice for young people looking after family members or friends.
• Get specialist advice about caring from condition-related organisations like Alzheimer’s Society, Age UK, MIND and others. Many offer support for carers too.

Look after your health as well as the person you support

• It’s important to look after yourself to stay healthy and avoid burning out. Eat a balanced diet, get enough sleep and try to make time each day for physical activity.
• Taking time for yourself to exercise or take a few breaths can relieve stress and help you manage each day. Check the NHS ‘Every Mind Matters’ website, www.nhs.uk/oneyou/every-mind-matters/ for more tips. If your own health or the health of the person you support gets worse, with coronavirus or another illness, talk to your GP or call NHS 111.

Think ahead to make care manageable if things change

• Write down what care the person needs and what others should do if you can’t continue providing care for any reason. It’s important that others can easily find your plan and quickly understand what needs to be done if you aren’t there. Carers UK has advice on their website on how to make your plan.

• Leaving hospital to go home
• Leaving hospital to go to another place of care

• Once you have been declared medically stable, you may require further health and social care assessments by the Discharge to Assess Service.
• These will be completed outside of the hospital setting and wherever possible, within your own home.
• Our ‘Home-first’ pathway has a range of services in place to help you to return safely to your own home.
• If we can’t assess you in your own home, your assessment will take place in one of our bed-based locations.
• This will be discussed with you at the earliest opportunity within the hospital.

It has been well researched that a hospital setting, in most cases, is not the most appropriate place to determine your long term needs.

Therefore a team of health professionals from the NHS and social services will help you do the things you need to do to stay independent.  This will be referred to as your “assessment”.

This might include help with getting dressed, preparing a meal, or getting up and the down stairs.

They might care for you at first, but will help you practice doing things on your own.

Your team might include:

• A nurse
• Carers
• An Occupational Therapist   
• Doctors
• A physiotherapist                              
• Social Worker

• The process will start with an holistic assessment that looks at what you can do.
• You will agree together what you can do and set out a plan for rehabilitation and reablement.
• The plan will include a contact person, who's in the team that provides your care and the times and dates they will visit you.
• This care package will support you in your assessment period, in the timeliest manner. The support provided is only short term.
• Your assessment period will determine your needs at the earliest possible opportunity. You will be involved in the assessment process at each stage. As soon as that assessment has been completed, you will be discharged from the service.
• Only a small percentage of people will need health funded care long term, and if your assessment outcome is that you have longer term support needs, the majority of individuals will be referred to the Local Authority to source your eligible social care needs.
• If you are eligible for Local Authority services post your period of assessment, you will be financially assessed to establish if you can afford to contribute towards your care. Your team will be support you with more information regarding this during your assessment process.

This process also start’s with an holistic assessment and looks at what you can do, you will agree this together and set out a plan for rehabilitation and reablement. 

The focus will be to try and get you back to your previous “home”, before your hospital stay. The plan will include a contact person, who's in the team that provides your care and the times and dates they will visit you.

The service will support you to retain your independence where ever practically possible and safe to do so. The support provided is only temporary and if you need a new care home placement after your assessment has been completed, in most cases, you will not remain in the current setting.  Your assessment period will determine your needs at the earliest possible opportunity.   

You will be involved and communicated with, as part of the assessment process at each stage.  As soon as your personalised assessment has been completed, you will be discharged from the service.

Only a small percentage of people will need health funded care long term, and if your assessment outcome is that you have longer term support needs, the majority of individuals will be referred to the Local Authority to source your eligible social care needs. 

If you are eligible for Local Authority services post your period of assessment, you will be financially assessed to establish if you can afford to contribute towards your care.  Your team will be support you with more information regarding this during your assessment process.

• NHS Continuing Healthcare means a package of ongoing care that is arranged and funded solely by the National Health Service (NHS). Such care is provided to an individual aged 18 or over to meet health and associated social care needs that have arisen as a result of disability, accident or illness.
  
  
• This is specifically for a relatively small number of individuals (with high levels of need) who are found to have a ‘primary health need’ The concept of a ‘primary health need’ helps determine which health services are the most appropriate to provide to meet your needs, and which services your Local Authorities may provide. A primary health need is not about the reason why someone requires care or support nor is it dependent on a diagnosis.  It is rather about the person’s overall actual day-to-day care needs taken in their totality.
  
  
• For individuals, over 18, who have a primary health need, funding can be paid regardless of where the individual lives for example; in a Care Home with Nursing, a Residential Care Home, whilst the individual is living in his or her own home, or if the individual is in supported living​.

• The first step in the assessment process for most individuals is screening using the Checklist Tool. The Checklist does not indicate whether you are eligible for NHS Continuing Healthcare, only whether you require a full assessment of eligibility. It is important to be aware that the majority of people who ‘screen in’ (have a ‘positive Checklist) are found not to be eligible once the full assessment has been done.
  
  
• For the full assessment of eligibility, a multidisciplinary team of professionals (usually referred to as the MDT) will assess whether or not you have a primary health need using the Decision Support Tool, (often referred to as the DST).
  
  
• Consent from the individual is required to share information with families as part of the assessment process, and consent to this should be obtained, if the individual has capacity to give it.
  
  
• If there is a concern that the individual may not have capacity to give consent, this should be determined using the principles set out in the Mental Capacity Act 2005.​
  
  
• Where it is established that someone lacks mental capacity, a ‘best interests’ decision should be made taking the individual’s previously expressed views into account.​

• For individuals in care homes with nursing, registered nurses are usually employed by the care home itself. In order to fund the provision of such nursing care by a registered nurse, the NHS makes a payment direct to the Nursing Home.
  
  
• This is called ‘NHS-funded Nursing Care’ and is a standard rate contribution towards the cost of providing registered nursing care for those individuals who are eligible. Local authorities are not permitted to provide or fund registered nursing care (except in very limited circumstances).

If you have a rapidly deteriorating condition which may be entering a terminal phase, then you may require ‘fast tracking’ to receive urgent access to NHS Continuing Healthcare.

In the Fast Track Pathway there is no requirement to complete a Checklist or the Decision Support Tool. Instead, an appropriate clinician will complete the Fast Track Pathway Tool to establish your eligibility for NHS Continuing Healthcare.

There are a number of end-of-life pathways which may be appropriate within local health and care systems and therefore not everyone at the end of their life will be eligible for, or require, NHS Continuing Healthcare. Care planning and support for those with end of life needs should be carried out in an integrated manner, as part of the individual’s overall end of life care pathway, taking into account individual preferences.

For help and advise or if you require signposting to other services once you are at home please contact;

Palliative Care Coordination Centre 03001230989 7 days a week 09:00hrs-20:00hrs

If your hospital assessment outcome determines you need little or no care post discharge, it is important to engage in “self-care” to maximise your independence and promote your wellbeing. 

There is lots of useful information, guidance, services and self help groups available to help people in our community to stay happy, healthy and independent.

Staffordshire Connects

Staffordshire Connects is a website that provides details about hundreds of different care, support and wellbeing organisations, local activities, clubs and community groups taking place across Staffordshire. Please visit: https://www.staffordshireconnects.info/kb5/staffordshire/directory/home.page

If you can’t find what you are looking for or need further support please contact the Contact Centre on Tel: 0300 111 800 Monday to Friday 9am to 5pm or Email: contactus@staffordshire.gov.uk

Stoke Adult Community Directory

This Community directory is an online tool to help you find out about activities, clubs, support, health services, self help groups and what’s on in Stoke on Trent. https://adults.stokecommunitydirectory.co.uk. If you can’t find what you are looking for or need further support please contact the Contact Centre on Tel: 0800 561 0015 Monday to Friday 9am to 5pm.

Staffordshire Foodbanks

There are a number of food banks in the Staffordshire area. For more information please visit Staffordshire Connects:

Website: www.staffordshireconnects.info select Children, Families and Care Leavers/Advice, Advocacy, and Keeping Safe/Food Banks.

Email: staffordshire.connects@staffordshire.gov.uk  

Stoke on Trent Foodbanks

There are also a number of foodbanks in Stoke-on-Trent. For more information please visit the Stoke-on-Trent Community Directory:

Website: www.adults.stokecommunitydirectory.co.uk select money, benefits and employment.

District Nursing is part of Community Nursing and provides nursing and end of life care to patients in the community.

• The client group is patients over the age of eighteen (housebound) that require a nursing skill or procedure to be carried out in their own home.
• District nurses visit patients in their own homes/residential care homes, assess their healthcare needs, review the quality of care they receive, support their family members and are professionally accountable for delivery of care.
• As well as providing direct patient care, district nurses also have a teaching role, working with patients to promote their independence or with family members teaching them how to give care to their relatives.
• District Nurses play a vital role in keeping hospital admissions and readmissions to a minimum and help to ensure patients can return to their own homes as soon as possible.
• Patients can access contact details for their local District Nursing service within their yellow notes folder. If you feel you or somebody else requires a referral following your discharge, please see your GP in the first instance.

Some of services which the District Nursing Team provides include:

• Assist patients to be independent and improve health
• Complex Care
• Co-ordinate care and work with other agencies
• Management of Long term conditions
• Palliative and terminal care
• Supported discharge
• Wound care/tissue viability
• Management of Diabetes

If you have already been referred into the District Nursing Service and you need to contact your local team, please see the contacts below:

(Please note if you need a referral then contact your GP in the first instance)

Burntwood, Lichfield and Tamworth

Tel: 0300 124 0347 - 24-hour contact number; also applies to out-of-hours calls (6pm-8am)

Email: sst-tr.bltlap@nhs.net (monitored between 8am-6.30pm Mon-Fri and 9am-5pm Weekends & Bank holidays)

Cannock and Seisdon

Tel: 0300 123 9011 - 24-hour contact number for Cannock and Seisdon; also applies to out-of-hours calls (6pm-8am)

Email for Cannock patients

Email (8am-6pm): cannock.localaccesspoint@nhs.net

Out-of-hours email (6pm-8am): mpft.seooh@nhs.net

Email for Seisdon patients

Email (8am-6pm): seisdon.lap@nhs.net  

Out-of-hours email (6pm-8am): mpft.seooh@nhs.net

The Community Intervention Service is also part of Community Nursing and provides support to patients in the community. This service helps to prevent hospital admissions and provides support following hospital discharge. They hold strong links with GP’s, Respiratory Services and District Nursing Teams.  Services which the Community Intervention Service provide include:

• Respiratory Exacerbation Monitoring
• IV Antibiotic Administration
• CVA Device Maintenance
• Health Monitoring
• Post-surgical/minor injury surgery dressing change for housebound patients
• Removal of sutures for housebound patients
• INR monitoring for unstable patients under the care of the Anticoagulation Clinic
• Follow up bloods for housebound patients
• Physiotherapy and Occupational therapy assessments and programmes of care to support housebound patients and reablement

There are many organisations, support groups and apps available if you feel you or somebody you know requires help.

Urgent Help

If you feel unable to cope, are worried about your own mental health or someone you care for, help is available. Call your local NHS urgent mental health helpline 24 hours a day, 7 days a week. 

• North Staffordshire Urgent Mental Health Helpline: call 08000 328 728 option 1(covers Stoke-on-Trent, Newcastle-under-Lyme, Staffs Moorlands).
• South Staffordshire Urgent Mental Health Helpline: call 0808 196 3002 (covers Stafford, Stone, Rugeley, Cannock, South Staffs, Lichfield, Burton, Uttoxeter, Tamworth).
• Contact NHS 111 online service or call 111 if you need urgent care but it’s not life-threatening. If you feel it is life-threatening then call 999.

Ask for an urgent GP appointment if:  

• You need help urgently for your mental health, but it's not an emergency
• You're not sure what to do 
• A GP can advise you about helpful treatments and also help you access mental health services.

There are there other useful services available for support:

North Staffordshire and Stoke

North Staffordshire & Stoke-on-Trent Wellbeing Service offers access to talking therapies, practical support and advice, quickly and easily.

Website: healthy-minds.org.uk (Self Referral)

Telephone: Referrals: 0300 303 0923

General Enquiries: 0300 123 0907 (option 2)

South Staffordshire Access Team (covers Stafford, Stone, Rugeley, Cannock, South Staffs, Lichfield, Burton, Uttoxeter, Tamworth):

This service ensures individuals are support by the right person, in the right place and at the right time. They offer talking therapies, practical support and advice.

South Staffordshire Access Team  

Telephone: 0808 196 3002

Mind

Mind is a national service that can also provide advice on mental health problems, where to get help and treatment options available.

Infoline: 0300 123 3393

Email: info@mind.org.uk

If you need housing advice during your hospital stay, the hospital team can sign post you to access the most appropriate service. If you feel you need help in the future you can visit your local council for advice on housing options, such as:

• Homelessness prevention/support for homeless, Housing standards, Landlord/Tenants advice, Energy efficiency, Homelessness prevention.

Please call or visit the website for you local area and select Housing:

Newcastle under Lyme

https://www.newcastle-staffs.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) 01782 717717

Emergency helpline 5pm-9am/Weekends: (01782 615599) NHA website: nhaoptions.co.uk

East Staffordshire

http://www.eaststaffsbc.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel: 01283 508120

Emergency helpline 5pm-9am/Weekends: Tel: 01283 508126

Staffordshire Moorlands

https://www.staffsmoorlands.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel: 0808 1968 199

Emergency helpline 5pm-9am/Weekends: 0808 1692 333 or Email: outofhourshousing-derbys@p3charity.org

Tamworth

https://www.tamworth.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel: 01827 709709.

Emergency helpline 5pm-9am/Weekends: Tel: 01827 709709 and choose option 1

Lichfield/Burntwood

https://www.lichfielddc.gov.uk/  https://www.burntwood-tc.gov.uk/

If Homeless/facing being homeless/harassment Helpline (Burntwood and Lichfield): in hours complete the  registration form on Jigsaw customer portal at https://www.lichfielddc.gov.uk/

Emergency helpline 5pm-9am/Weekends: Tel: 01543 574480.

Cannock Chase

https://www.cannockchasedc.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel: 01543 462621.

Emergency helpline 5pm-9am/Weekends: Tel: 01543 462621.

Stafford

https://www.staffordbc.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel:01785 619000

Emergency helpline 5pm-9am/Weekends: Tel: 01785 619170   

Email: housingadvice@staffordbc.gov.uk

South Staffordshire

https://www.sstaffs.gov.uk/

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel: 01902 696000

Emergency helpline 5pm-9am/Weekends: Tel:01902 696000

Stoke-on-Trent

https://www.stoke.gov.uk

If Homeless/facing being homeless/harassment: Helpline: (9am-5pm) Tel: 01782 234234

Emergency helpline 5pm-9am/Weekends: Tel:01782 233696

It is important to make sure that you get all the help that you're entitled to. The following contacts give you information on benefits and tax credits if you are working or unemployed, sick or disabled, a parent, a young person, an older person or a veteran. There is also information about council tax and housing costs, national insurance, payment of benefits and problems with benefits.

Citizens Advice

Website: https://www.citizensadvice.org.uk/benefits

Telephone: 0800 144 8848

Website: www.gov.uk/browse/benefits

Telephone: 0800 731 0469

Following your discharge, If you feel you or somebody you know, cannot cope with your personal care needs and there is nobody to help, the first step is to get a needs assessment from your local council.

How to get a needs assessment:

• Contact social services at your local council and ask for a needs assessment. You can call them or do it online.
• You'll need to have this assessment before the council can recommend a service such as:
• equipment like a walking frame or personal alarm
• changes to your home such as a walk-in shower
• practical help from a paid carer
• day care for your child if either you or they are disabled
• access to day centres and lunch clubs
• moving to a care home
• The needs assessment is free and anyone can ask for one.

Please note: Adult social care in England is, unlike healthcare, not a free service. Many people will have to pay a contribution towards, or pay the full cost of, their care and support. Services are defined by  eligibility criteria and if you require long term services you will be financially assessed.

Stoke on Trent City Council

Please contact the Social Care Contact Centre:

Tel: 0800 5610015

Email: social.care@stoke.gov.uk

Website: www.stoke.gov.uk 

Staffordshire County Council

Please contact Staffordshire Cares

Tel: 0300 111 8010

Email: staffordshirecares@staffordshire.gov.uk

Website: www.staffordshire.gov.uk