Transfer of Care: Hospital to Home

 

When do we start planning your transfer of care?

Within 24-48 hours of your admission to hospital, the team looking after you will decide on an estimated date of discharge (EDD). Your progress will be reviewed daily by the nurse coordinating your discharge or discharge coordinator and if there is likely to be a change to this estimated date you will be kept updated.

 

Why do we start planning so early?

  • We start planning as soon as possible to help minimise any delays in your transfer of care once you are ready to leave hospital. Some people will need only a small amount of support on leaving hospital, others will need much more. If you require more, a comprehensive multi-disciplinary plan will be developed and that will include physiotherapist, occupational therapist, social work team etc.

  • You and your family (with your permission) will be fully involved in this process and your views are important in planning. This planning process does not always have to happen whilst you are in hospital, in fact evidence suggests that this is better done in your own home or within a community setting.

  • The patient flow team assess medically well patients who have recovered and are stable to transfer from an Acute Hospital bed to another destination.

  • This could be to another Ward or Department within the hospital if you have a discharge plan and are leaving within the next 24-72 hours.

  • Your transfer will be explained to you and your family then arranged between departments where your journey home will continue as planned.

 

What sort of arrangements need to be made?

  • Medication – we will return any medication to you that you may have brought in from home, along with any newly prescribed medication from the hospital pharmacy. It is important to let us know if you already have supplies of medicines at home. We will explain your medication to you before discharge, but if you require any more information please ask your nurse or doctor.

  • Follow up appointments – we will make any follow up appointments necessary. This may be to return to the hospital as an outpatient, investigations, district nurses etc.

  • Equipment – if you need any equipment to support you at home, arrangements will be made and discussed with you as part of your care plan.

  • Transport arrangements – you will need to arrange your own transport home, please arrange for a friend or relative to collect you. If your care is being transferred to another setting, we will arrange appropriate transport for you.

  • Thinking ahead – please make sure you have your keys, outdoor clothing and footwear. You may wish to arrange someone to help you with this. This person may also help make sure you have food and drink at home, and that your heating is on.

 

What if your home care services are not ready?

If your services are not available when you are medically well enough to leave hospital, we will need to make alternative arrangements on a short term basis. These arrangements might include a residential or nursing home until your services can commence. We will support you and give you the information you need to make this decision. It is not suitable for you to stay in hospital due to the negative impact it can have on your health outcomes.

 

What happens on the day you leave?

We will assist you to be ready to leave your bed by 10am. In most cases, you will be asked to wait for your medications and transport home in the Discharge Hospitality Lounge. Here you can wait in comfort for your relative/carer/transport to arrive. There will be nurses and support workers who will help ensure all arrangements are in place to get you home. This enables the ward team to begin treating another patient. We will send a discharge letter to your GP explaining the reason for your hospital stay and any follow-up plan.

 

You may also find it useful to contact:

  • Your GP
  • NHS Choices http://www.nhs.uk
  • NHS 111
  • Gateshead Adult Social Care Direct – 0191 4337033

Call us on 0191 482 0000

In emergencies dial 999 / Non-emergencies dial 111

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