Patient information leaflets
Who is this guidance intended to help?
This guide has been prepared for anyone who has been admitted into the Borders General Hospital, Mental Health inpatient ward or a Community Hospital for medical treatment and are now ready to be discharged from hospital-based care into a care home or back to their own home with additional support.
Discharge from Hospital
NHS Borders and Scottish Borders Council have a responsibility to ensure adequate processes are in place for patients to be safely and timely discharged. The decision to discharge a patient from hospital-based care is based on clinical need and is the responsibility of the multi-disciplinary team responsible for the patient who will assess their patients’ needs before developing a discharge plan.
Not all patients are able to return home without additional support being in place or alternatively, some patients may require to be admitted to a care home. In this situation, patients will have been assessed by a Social Work & Practice Professional as requiring additional support. A financial assessment may also need to be completed. The assessment process may continue even if a person has moved to their own home or a care home. This is to ensure that people have the best opportunity to recover and return to their own home permanently, with support if needed, or to another type of care such as a care home or supported accommodation.
Why is a care home recommended for me?
Health and Social Care staff will have discussed and planned a patient’s future long-term care needs with the patient, family, carer and/or proxy. This assessment will have recommended that a patient needs a particular type of care home to best meet their needs, and the support they will need after discharge.
Moving into a care home is a very personal and sensitive decision for a person and their family so it is important that careful preparation and planning starts as early as possible. The assessment will be shared with the patient, family, carer and/or proxy who will be given the opportunity to discuss its contents.
Moving from hospital to a care home
If a person needs to move to a care home, their future, long term care needs will be agreed with the patient, carer, family and/or proxy as part of the assessment process. This is usually done by a Health and Social Care Practitioner based in the hospital. The assessment should be discussed with the patient, carer, family, carer and/or proxy (if the patient agrees).
The patient should receive a copy of the assessment and be given the opportunity to discuss it.
The Social Work and Practice assessment (in part or full) will be shared with relevant third parties such as Care Homes or Service Providers and the patient, carer, family and/or proxy will be informed of the third parties involved. This allows the Care Home/Service provider to establish if they can meet the person’s needs. For more information on Social Work and Practice please refer to the Scottish Borders Council Website via the links included in the Useful Contacts & Information section of this leaflet.
How a care home is chosen
A plan for the type of care home that will best meet your needs will be created in partnership with the patient, their family, carer and/or proxy. From that point, patients can then see a list of suitable homes that can meet their needs.
Patients must choose three care homes from the list provided to them by their Social Work & Practice
Professional, preferably at least one with a vacancy, and they should be ranked in order of preference. Patients have seven days to confirm these choices with the Nurse in Charge of the ward. If there are no current vacancies in any of the preferred homes, an interim placement will be found in a temporary alternative home with a vacancy that can also meet your needs. This will either be one of the other homes on the list, or it may be a different home.
Patients will still be added to the waiting list(s) of the preferred home(s) and the care home will get in touch when a place becomes available. Patients will then be given the option to move there if they still want to go there.
What is an interim care home?
An interim care home allows a patient to leave hospital while waiting for their preferred care home place or whilst awaiting a package of care to allow them to go home. While the patient is in the interim care home, updates can be requested regarding availability of the preferred care home or package of care from the Social Work Department.
When a vacancy arises or a package of care becomes available, the person will be able to move to their
preferred care home or be discharged home.
Why can’t I wait in hospital?
Hospitals are the best place when people need medical treatment or interventions. Once these are finished and patients are medically fit to be discharged, it is important that you are discharged safely and promptly. No-one wants to remain in hospital any longer than they need to. A long delay can often lead to people becoming ill again, deteriorating, or becoming more dependent.
A delay in moving medically fit people from hospital could also mean that treatment may be delayed for other people waiting for the bed or service.
Research shows that staying in hospital after people are medically better can be damaging to their physical and mental wellbeing and can result in:
- A sense of isolation from family, friends and their usual social networks leading to boredom, loneliness, hopelessness, confusion, and depression.
- Increased vulnerability to hospital-associated infection and a higher risk of delirium, pressure sores, muscle wastage and falls.
- Loss of confidence and ability to cope at home, resulting in a premature shift to permanent care, particularly for people with dementia.
- Distress to the patient, family, carer and/or proxy as they are unable to plan for the discharge date, and have to spend more time and money on regular, frequent visits to the hospital
It is important for people’s long-term health and wellbeing that they are as well as they can be, in a safe,
comfortable, and homely setting. The Scottish Government is clear that no-one has the right to ‘choose’ to stay in hospital. Not engaging with the discharge process or not choosing a care home will not stop discharge taking place. If patients are reluctant to move to an interim care home, an Integrated Discharge Case Conference will be held to reach a mutual agreement regarding a transfer to the patient’s next place of care.