Discharge to Assess
We will plan your discharge from the moment you are admitted to hospital. On the day you no longer require hospital care, a ‘Discharge to Assess’ process will be followed.
You will be assessed to decided where is the best place to complete your recovery. Usually, this will be in your own home, where our community teams will then complete a full assessment of your health and social care needs.
You will only leave hospital when it is safe to do so.
However, you will not be able to remain in hospital if you choose not to accept the care that is being offered.
Our team will try their best to get you home with the support you need and back to normal as soon as possible.
If your admission is planned, it is vital you prepare for your discharge before coming into hospital. Your needs will be discussed with you and your family, if you would like them involved.
Including friends and family in your conversations will help identify what support they can provide and what extra support you may need.
Home – Pathway 0
Once our health and social care team agree it’s safe you’ll be discharged home. A volunteer from the ‘Home from Hospital’ service can support you in getting home and settling back into your house.
In most cases, the best place for you to recovery will be in your own home, where you can recover at your own pace with your existing care support.
A volunteer working with the discharge team will telephone you to check on your recovery.
Home with support – Pathway 1
We will work with health and social care providers to ensure that any initial support is available for when you return home. This support could include help with self-care, cooking and shopping.
Our team will continue to support you at home, before making an assessment for your longer-term care needs.
If you need support at home, you may be eligible for your initial care to be provided without charge. This will be assessed at the point of discharge.
If you require longer-term support, you will be financially assessed and may need to contribute to the cost of your care. You may be eligible for benefits to help towards the cost of long-term care and support.
This will all be explained while the assessment is completed.
Community recovery – Pathway 2
You may need a period of rehabilitation in order to reach your full potential of independence. We can offer 4 types of recovery in a bedded setting.
- Eden court and Connie Lewcock
- Byker Lodge
- Recovery Units.
At Connie Lewcock and Eden Court, patients are assisted in the learning of new skills, building stamina and are assessed for suitability for equipment.
Connie Lewcock supports patients with minimal nursing care needs.
Eden court supports patients with more complex needs who require medical and nursing supervision.
Byker Lodge assesses patients to determine what mental health support they require so they can return home safely, but it does not provide any physical rehabilitation.
Recovery units support patients who are unable to return home because it is not a safe environment, for example is their home requires adaptations or equipment or if they require a package of care which is not readily available when they are discharged from hospital.
You will not stay in the recovery unit long term and are expected to be back home within 4 weeks.
Care home – pathway 3
Wherever possible, we will try to return you to your own home, but sometimes, it may not be suitable.
This is usually a last resort, but a care home may be the only safe option to ensure your full recovery.
All transfers to care homes will be temporary until a social worker has assessed what extra support you require to be in your own home.
For people with very high needs, this may not be possible, and a permanent care home place might be considered.
You may have an option to remain in the temporary placement or a social worker can support you to choose an alternative care home. Moving to a long-term placement may have financial implications. A social worker can arrange for a financial assessment to provide you with information about how much you might need to contribute towards the cost of a care home.
