The Assessment and Discharge process

Patient Information Leaflet

FACTSHEET A: The Assessment and Discharge Process

Discharge Pathways:

Pathway 1 – Package of care (POC) – Funded via Social Care.

This could be up to a maximum of four calls per day with two carers. A POC will support patients with personal care, meal provision, and medication administration. They will not complete domestic tasks such as cleaning, shopping, washing clothes etc.

Pathway 2 – Rehabilitation in a bedded facility – Funded via CCG

Also known as ICT (Intermediate Care). This pathway is for patients who are not ready to be discharged home as they still require on-going therapy in order to regain some level of independence. Patients who are considered for this pathway should have set rehab goals by a therapist and show some level of improvement during their admission. Due to the length of stay some patient’s functional ability may decline. This pathway enables them to have intense rehabilitation in order to return to or near their baseline.

Pathway 3 – 24 hour care – Joint funded via CCG and Social Care

This pathway is for patients who are no longer able to cope at home even with support services. There are two types of 24 hour care settings. Residential care settings – For patients who don’t require on-going nursing intervention and are able to walk or transfer with the assistance of one.

We want to give you the support you need to get home as quickly as possible. Following a hospital admission, most patients are able to return home, sometimes with a care package or adaptations made to their home. However, some patients are unable to return home and need the added support only available in a care home.

We will involve you in all decisions about your care, treatment, and discharge, and give you all the information and support you need to make the best decisions.

What can you expect to happen?

• We will tell you when your treatment is due to end and when you would be considered well enough to leave hospital (this is called an estimated discharge date) – we aim to tell you this within 48 hours of you being admitted and will discuss with you if this changes.
• We will provide you with a named staff member who will support you throughout your time in hospital and on discharge and make sure that things happen when they are supposed to.
• We will tell you how to access information, advice, and support to help you make your discharge decision. This will include helping you to understand your care needs, the process of assessing your needs and the care options available to you.
• With your permission, we will request assessment(s) to find out what needs you have and the services you might need to be safely discharged from hospital. The assessments could be for social care, home assessment for any adaptations, eligibility for NHS continuing healthcare, etc.
• It may also be necessary to assess how any ongoing care will be funded, although in most circumstances to avoid any delay this will be carried out after you have been discharged. It is important to note that whilst NHS care is free to everyone, social care is not. Speak with your named staff member to find out what the time limits are for free care and what this might mean for you.
• If your preferred choice is not available when you are ready for discharge, an alternative option can be arranged for you temporarily. It is not possible for you to wait in this hospital once you no longer need hospital care.
• If you wish to make a complaint or appeal against any part of the discharge process then contact at any point The Patient Advice & Liaison Service, based at Russell’s Hall.

If you would like a copy of this factsheet to be given to someone else or you have any questions, please speak to one of the nurses on your ward or any member of the team caring for you.

Please do not hesitate to ask questions about your discharge at any time during your hospital stay.

With best wishes for a speedy recovery.

Compliments or Complaints

For compliments or for complaints please contact patient advice and liaison services (PALS).

Available Monday to Friday 9am-5pm

Telephone – 0800 073 0510 or 01384 244420

Email – dgft.pals@nhs.net

We care: Please treat us with respect

We work for the NHS because we want to care for you. We will always treat you with respect, kindness and compassion.

Your safety and the safety of our colleagues is our top priority, If staff are subjected to abuse or violent behaviour, we can refuse treatment and take further action. Our organisation operates a zero tolerance approach to all such incidents.

If you have any questions, or if there is anything you do not understand about this leaflet, please contact:

Complex Discharge Team: ext 816

Russells Hall Hospital switchboard number: 01384 456111

If you have any feedback on this patient information leaflet, please email dgft.patient.information@nhs.net

Originator: Discharge Team. Date reviewed: January 2025. Next review due: January 2027. Version: 1. DGH ref: DGH/PIL/02228