Whether a person is admitted to hospital in a planned way or in an emergency, consideration is given at once as to how to support their discharge home or to another suitable place. Usually a nurse or nursing team on the ward admitted to will take charge of the person’s care and discharge planning on the ward. They will gather information from the person, their family, carers and Orkney Health and Care (OHAC) about their circumstances so as to be able to make plans to meet their needs during treatment, recovery and for eventual discharge.
If the person already has a social worker or occupational therapist involved in their care, they will continue to be involved in discharge planning. If there is no Adult Social Work Teams (ASWT) involvement and this would be useful or essential in planning for services to assist with discharge, the nursing team will make a referral to ASWT for a worker to be allocated to take part in discharge planning, to record a Single Shared Assessment (SSA) and to commission services that will be required.
Whilst in hospital, the person will be seen by doctors, physiotherapists, occupational therapists and speech and language therapists along with the dietician. The pharmacist will oversee their medications for discharge. Everyone will contribute to the SSA and the person will be involved in decisions about care and assistance recommended for a successful discharge.
Where the person has made a good recovery and is assessed as being able to go to their home or the home of a family member or friend on discharge, services will be offered to support them once home. These may consist of Home Care to help with personal care, getting to the toilet or in and out of bed and with having meals provided. Personal care for people over 65 is free. Additional non-personal care Home Care help over and above what the person may have had prior to admission to hospital is also free for the first four weeks after discharge. Assistance will be provided by Occupational Therapists to ensure that the person can manage as independently as possible at home. Sometimes a safe discharge will not be possible until services can be put in place. The person may need to remain in hospital for a while longer or move on a temporary basis to a family member’s home or care home, for example, until services or adaptations can be put in place. The Intermediate Care Team may support discharge and continue rehabilitation at home.
After a thorough assessment, it may become clear that the person cannot safely return home because they need a higher level of care than can be provided there, or because their home is no longer suitable for their needs, or because their informal carers can no longer continue.
A case conference will usually be held to look at what options are available so that the person can leave hospital. Examples of options could be a move to alternative housing, sheltered or very sheltered housing or to a care home. The person’s social worker or occupational therapist will help to make applications for suitable accommodation and will write a care plan outlining the person’s care needs.
Sometimes there will be a delay whilst waiting for new accommodation or a care home place and it may be necessary for the person to move within the hospital to wait or to move to a respite bed in a care home to avoid a hospital bed being blocked.
People whose medical needs have been met cannot remain in hospital indefinitely.
Very occasionally a person will have continuing medical care needs that mean they cannot be discharged from hospital because no other facility could meet their needs. Such people receive continuing care but their situation is kept under review by the doctor in charge of their care. If they improve such that their care could be managed outside a hospital, a worker from the ASWT will undertake a SSA to inform about where they can be discharged to, most usually to a residential care home.