This service is managed by Health and Community Care
Hospital discharge
Whether you come into hospital as an emergency or for a planned procedure, planning for your discharge home begins straight away. Usually a nurse or nursing team takes the lead on your care and discharge planning, gathering information from you, your family, carers and Orkney Health and Care to help make plans for your treatment, recovery and eventual return home.
How we get involved
If you already have a social worker or occupational therapist, they will continue to be involved in your discharge planning. If not, and it would be helpful, the nursing team can make a referral to the Adult Social Work Team for a worker to take part in your discharge planning, carry out an assessment and arrange any services you will need.
While you are in hospital, doctors, physiotherapists, occupational therapists, speech and language therapists and a dietician will all contribute to your assessment. The pharmacist will oversee your medications for discharge.
Going home
If you have recovered well and can return home safely, services will be arranged to support you when you get there. These may include home care to help with personal care, getting to the toilet, getting in and out of bed or having meals provided.
Personal care for people aged 65 and over is free of charge. Additional non-personal care help beyond what you had before going into hospital is also free for the first four weeks after discharge.
Occupational therapists will help make sure you can manage as independently as possible at home. Sometimes a safe discharge cannot happen straight away - for example, while services or home adaptations are being put in place. In these cases you may need to remain in hospital a little longer, or move temporarily to a family member's home or a care home while everything is arranged. The Intermediate Care Team can also support your discharge and continue your rehabilitation at home.
If you cannot return home
After a thorough assessment, it may become clear that you cannot safely return home because you need a higher level of care, your home is no longer suitable, or your carers are no longer able to continue. In this case, a case conference will usually be held to look at what options are available.
Options might include moving to alternative housing, sheltered or very sheltered housing, or a care home. Your social worker or occupational therapist will help with applications for suitable accommodation and write a care plan setting out your needs.
Sometimes there may be a wait for a suitable place, and it may be necessary to move within the hospital or to a short-term respite bed in a care home in the meantime.
NHS continuing care
Very occasionally someone's medical needs mean they cannot be discharged to any other setting. These people receive continuing care in hospital, but their situation is kept under review. If they improve to the point where their care could be managed outside hospital, a social worker will carry out an assessment and plan for their discharge, usually to a residential care home.