Checklist for your recovery and follow-up

  • Be aware of signs of health deterioration and how to manage them. Ask your nurse before you leave hospital if you are unsure.
  • If you are admitted regularly to hospital for the same health issue, please ensure you are referred to a specialist service to help you self-manage your condition.
  • Make an appointment with your GP to review your discharge letter and medications list (if needed).
  • Contact your local pharmacist if you need more advice regarding your medications.
  • Ensure you have made a note in your calendar of any follow-up appointments or investigations booked for you.
  • If you have not heard back from the hospital regarding future appointments, contact the relevant department to ensure this is corrected as soon as possible.
  • Ensure that your cannula has been removed.
  • If you have a new catheter on discharge, ensure you have been given a supply of day and night bags and a catheter passport.

If you were living in a care home prior to admission, and your needs are unchanged following your hospital stay, you will return to your care home. The hospital will contact your care home before discharging you to let them know your date of discharge.

You must continue paying for your care home (whether you are self-funding or someone else is paying for your care) whilst you are in hospital. Giving notice to your care home will most likely delay your discharge from hospital, and so is not in your best interests. If you wish to change care home this should be arranged with your current care home once you have been discharged.

If your needs have significantly changed or you are no longer able to immediately return to your own home or care home, the hospital staff and other services will help with the assessment process required to identify a more suitable temporary placement so any longer-term needs can be assessed. You and/or your family will be involved in this process to ensure your voice and preferences are heard.

If your needs have not changed:

• Social Services-funded care support packages will re-start when you are discharged. The hospital will inform your care provider of the date and time you will be back at home.

• Self-funded care packages will re-start once the care agency has been informed of your discharge date. The care agency usually requires at least a few hours’ notice, so we advise that you contact them as soon as you are informed of your discharge date.

What other services are available?

A discharge pathway recommendation will be made by the Transfer of Care team following information gathering and discussions with the ward staff, yourself and your friends/family. If it is identified you require further support on discharge it may be suggested you are supported by one of the following services:

Home First is a service that completes an assessment within your own environment to determine your ongoing care, rehabilitation and/or equipment needs following on from your hospital stay. On discharge from hospital, you will be met at home by a member of the Home First team who will assess your function and prescribe any care or equipment that may make things easier for you. They will also complete any onward referrals to teams who will assist you to continue your recovery at home. This initiative has close links with Social Services and you will be followed up by a member of their team within 3 days of hospital discharge.

If you are not at your pre-admission functional ability it may be suggested you have some further rehabilitation. This may either be as an inpatient or within your own home.

Bed-based services – Bed-based services provide rehabilitation in community hospitals or care home settings with the support of a multidisciplinary team. These beds are identified for patients who may have higher needs requiring more input. Our local bed-based services include Clifton Hospital, ARC (Assessment and Rehabilitation Centre), Thornton House and Dolphinlee. 

Home-based services – rehabilitation input within your own home (or care home). This may be delivered by Early Supported Discharge (ESD) or our Community Neighbourhood/Enhanced Primary Care teams. They will visit you on discharge from hospital and work towards achieving your goals and regaining your independence.

If you suffer from complex or long-term health conditions and are at risk of frequent hospital re-admissions, you may be referred to other services such as:

• Rapid Response.

• Community Frailty services.

• Heart Failure services.

• Diabetes services.

• Tissue Viability services.

• Falls Service.

• Memory clinics.