Supporting you through your stay and preparing for a safe return home
- Your journey through hospital
- Transport home
- On your day of discharge
- Funding and assessment
- Adult social care
- Support for unpaid carers
- Support in the community
- Housing and homelessness
- Key contacts
Useful resources:
- Download the Planning your Discharge or Transfer from Hospital Guide
- Download the Admissions and Discharge Booklet
Your journey through hospital
On admission
- You will meet your team of healthcare professionals
- We will begin to discuss your expected discharge date with you early on
- It is important that you tell your care team if anything may affect your discharge
During your stay
- You will receive treatment and nursing care from your healthcare team
- Our therapists may assess what additional support you may need at home so that this can be put in place before you leave the hospital
- If required, a Discharge to Assess (D2A) referral will be made
When you are well enough to go home (medically fit)
- We aim for all patients to discharged on the same day they are declared medically fit. Once everything is ready for you, you will be moved to our Discharge Lounge where you can wait comfortably whilst we finalise everything
- If discharge is delayed, you may move to a non-acute area to keep medical beds available for patients who are need medical care
- If you become medically unwell whilst preparing to leave the hospital, your discharge will be postponed whilst we provide additional care to get you medically well enough to return home
Transport home
Hospital transport is available for those with a medical need. If you are not eligible for hospital transport, you will need to arrange your own transport home - this could be through a family member, friend, carer or local taxi service. Out of area transport without medical need must be paid for.
More information about hospital transport elibility criteria and local travel options.
On your day of discharge
- Please be ready to leave your bed by 8.30am
- We will give you your medication, discharge letter, and any equipment you need
- Your existing care packages will be restarted ahead of your of discharge
Going home checklist
Have you:
- Told family / friends you’re coming home
- Got your house key or key code
- Got food and heating ready at home
- Received your medication and discharge letter
Funding and assessments
If it has been identified that you may need care and support after leaving hospital, a referral will be made to the Transfer of Care Hub. This team will review your needs and, where appropriate, arrange support from the service best suited to help you leave hospital safely.
Any assessment of your longer-term care and support needs will take place after discharge, in your own home or another community setting. This helps ensure that decisions are based on how you are managing in your usual environment.
Self-funders
If you are deemed as have savings above £24,500 or do not meet the eligibility for short-term care support or local authority criteria, you will be referred to the private funder officers. They can help arrange home care packages, live in carers, respite, and long-term placements.
Adult social care
An adult social care worker may speak with you in hospital to understand your immediate care and support needs and help to plan a safe discharge.
Your longer-term care needs are usually assessed after you leave hospital, in your own home or another community setting. This gives a more accurate picture of the support you need once you have started your recovery.
If ongoing care or support is required, adult social care will discuss the available options with you and, where appropriate, your family or carers.
Support for unpaid carers
If you care for someone who could not manage without you, you can be referred for a carer’s assessment via your local authority.
We also recommend registering as an unpaid carer with your GP.
Support in the community
If your healthcare team identifies that you would benefit from inpatient rehabilitation, you may be referred to a community hospital to continue your recovery. This service is intended for patients who can actively participate in therapy and work towards specific rehabilitation goals.
Please be aware that there may be a waiting period for a rehabilitation bed due to demand.
At home options
- Reablement: a therapy-led service for adults (18+) that provides personalised, strengths-based support for a period ranging from a few days up to six weeks, helping people regain or maintain their independence
- Community rehabilitation team: Short-term physiotherapy or home environment checks
Housing and homelessness
If you are homeless or facing eviction, please tell your care team when you are admitted.
The complex discharge team will liaise with the district and borough councils.
Temporary accommodation may be provided following a council assessment.
The team can also provide contact details for local hostels and shelters.
Key contacts
Complex discharge team
Monday to Friday, 9am to 6pm
01932 723591
Switchboard
Weekends, 8am to 4pm
01932 872000 - bleep 5034
Patient Advice and Liaision Service (PALS)
Monday to Friday, 9am to 4pm
01932 723553 -
