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Hospital To Home

What is home care?

Home care is a range of support and care services provided to people in their own homes. It is typically aimed at elderly people, those with disabilities, and people recovering from illness or surgery.


You may have to consider home care if you are finding it difficult to cope with daily routines, such as taking care of your own personal hygiene, getting dressed or getting out independently, or if you do not wish to move into a care home but you need additional help in order to remain living in your own home. Having home care in place should generally improve your quality of life on a day-to-day basis.

Home care can cover a wide range of help at home, including:

Personal care – this can include assistance with tasks like getting out of bed in the morning, bathing, dressing and toileting.

Help with medication – this can include help with administering medicine or simply reminders to take it.

Emotional support and companionship – this can include participation in social activities, providing emotional support and someone to talk to.

Help with household chores – this can include cleaning, laundry, shopping and other household tasks.

Assistance with mobility issues – this can include assistance with mobility and transfers, using mobility aids if necessary.

Support for people to be as active as possible – this will depend on the capabilities of the individual receiving the care.

Health monitoring– this can include observing and reporting any changes in health or well-being.

Respite care – this can help to give family carers a break for a short period of time.

End-of-life care this can include any type of help or care needed when someone has a terminal illness.

If you are requiring care within your home in the short term, this is known as reablement. Reablement usually involves a group of care workers from different sectors who provide different approaches and support within your own home. The reablement services that are available for different individuals can vary, depending on your condition. They are usually offered at the appropriate level needed in order to increase independence, so that people do not become dependent upon the support given to them. Reablement is usually needed as a result of an illness or injury and most reablement programmes last between two and six weeks. The NHS only provides a maximum of six funded weeks of reablement, after which, adult social services and private services are responsible for providing other care options.

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Home care can be beneficial for people who require extra care in order for them to be able to remain living in their own homes. This can include:

  • The elderly. Post-surgery patients.

  • People with disabilities.

  • People with a chronic health condition.

  • People with an advanced, progressive illness. This is also known as palliative care.

  • People with a terminal illness and those requiring end-of-life care.

How is the transition from hospital to home care done?

A successful discharge means a patient being ready to leave hospital and be able to safely manage their condition at home. Discharge from hospital to home requires the successful transfer of information from medical professionals to the patient and family in order to reduce adverse events and prevent unnecessary readmissions. Patients and families need to be part of the discharge planning process as this is found to make the transition in care safe and effective.


The patient and family members should be prepared as much as is possible for what life at home will be like, they should have an understanding of their condition and any medication requirements, understand how to spot warning signs and problems and have the dates of any follow-up appointments.


Registered managers and their teams have an important role to play as part of the community-based team supporting people transferring in and out of hospital. They should think about who might be at risk of hospital admission and support them to make a care plan in the event that this happens. They should be familiar with the hospital discharge planning protocols and processes. The care team should have all the information they need about the person. This might include any medication they are on, care plans, including any preferred routines, and advance care plans, communication and accessibility needs, family, including carers and next of kin, and any housing issues.

Good communication between professionals is vital and can prevent:

  •  Avoidable hospital readmissions.

  •  Unnecessary admissions to care homes.

  •  Care and support needs remaining unmet.

  •  Delayed transfers of care.

The discharge coordinator at the hospital is responsible for:

  •  Agreeing a discharge plan with the person and the community-based team.

  •  Arranging follow-up care and any specialist equipment and support that may be needed.

  •  Agreeing the plan for ongoing treatment and support with the community team and maintaining regular contact with them.

A copy of the discharge plan should be given to the patient and family and also the team responsible for providing the home care. A discharge plan sets out the kind of care the patient will need after they leave the hospital. Discharge plans can help to prevent future readmissions, and they should make the move from the hospital to home or another facility as smooth and as safe as possible

A discharge plan should include:

  •  Information about the person’s condition.

  •  Information about medication.

  •  Contact information for after they have been discharged.

  •  Arrangements for social and health care support, including family support.

  •  Information and contact details of other useful services.

People who need end-of-life care or who have complex needs should have the details of who to contact in case any problems with medicines or equipment occur within 24 hours of discharge.

The National Institute for Health and Care Excellence (NICE) quality standard on end-of-life care for adults says that “people approaching the end of life should receive consistent care that is coordinated effectively across all relevant settings and services at any time of day or night. This should be delivered by practitioners who are aware of the person’s current medical condition, care plan and preferences”.

The term end-of-life care usually refers to the last year of life, although for some people with a terminal condition, this may be significantly shorter. It is intended to enable people to live as well as possible until they die, and when the time comes, to die with dignity.

People in these circumstances also benefit from having an advanced care plan where possible. Advanced care planning involves discussing and preparing for future decisions about your medical care if you become seriously ill or unable to communicate your wishes. The National Audit of Care at the End of Life found that there has been an increase in advanced care plans, but the latest audit shows that 9 out of 10 people did not have one on arrival at their final hospital admission. Around half of the people in their final hospital admission lack the capacity to make decisions about their care and would benefit from having an advanced care plan in place.

If someone is at risk of readmission, the GP or community-based nurse will telephone or visit them 24 to 72 hours after discharge.

NICE have issued guidelines which cover the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people’s experience of admission to and discharge from hospital by ensuring better coordination of health and social care services.

When to plan the transition from hospital to home care

During the hospital stay the care team should keep in touch with the hospital team and share any information which might affect discharge planning. This includes working with the discharge coordinator to help develop the discharge plan. Discharges should be planned and coordinated, despite whether there is any pressure on beds. Discharge planning should begin from the point of admission so that everything is considered and decisions are not made in a rush or under pressure. This should include:

  •  Referring to any existing care plans.

  •  Selecting a hospital-based team according to the person’s individual needs.

  •  Continuously assessing the person’s current and ongoing health and social care needs and referring back to these before any recommendations are made.

  •  Discussing with the patient and family members throughout the process.

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What happens at discharge from hospital?

As soon as you are admitted to hospital, your treatment plan, including details for discharge or transfer, will be developed and discussed with you.

For some people, especially if they have had an extended hospital stay or they are requiring additional care once they leave, being discharged from hospital can be just as unsettling as going into hospital in the first place. Having a hospital discharge process is good practice for the hospital but it can also be reassuring for the patient and family to know what will happen next.

A discharge assessment will determine whether you need further care after you leave hospital; this will also be discussed with you and you should be part of this process. Your family or support network can also be part of this process, if you would like them to be.

Each hospital will have its own discharge policy and the process may vary slightly. You can ask the ward manager for a copy of this if you are unsure.

During your stay in hospital, staff will discuss with you:

  •  How it will be decided that you are ready to be discharged from hospital and when that is likely to be.

  •  Whether it will be an option for you to go home or whether you will need to go to another setting.

  •  If you will be going home, whether you will need home care and what that will consist of.

  •  Any other support or care you may need.

  •  Transport requirements or any other arrangements.

Medical professionals use two terms to describe hospital discharges. These are either minimal discharges or complex discharges. A minimal discharge means that the patient will need little or no additional care once they leave hospital. A minimal discharge is one that can be carried out at ward level with the multidisciplinary team. A complex discharge indicates that the patient will need more complex care post-discharge from hospital.

If you need care and support after you are discharged from hospital, staff will talk to you about how you can get this. They will work with social care staff, if necessary, to plan your short-term care.

If you are likely to have long-term health and care needs, social care will arrange a care needs assessment. This may occur while you are still in hospital or in your home once you have been discharged. A care needs assessment is where someone from your local authority such as a social worker or occupational therapist will ask you how you are managing everyday tasks like washing, dressing and cooking. They will also gather information from the hospital about your needs which will feed into the assessment. The assessment might take place in person or over the phone.

There’s no charge for a care needs assessment and you are entitled to one regardless of income, savings or level of need. A relative or a friend can also make arrangements for you to have a care needs assessment as long as you give consent for this. You may have to pay towards the costs of long-term care and support but this should all be explained to you during the assessment process.

You can find information about how to apply for a care needs assessment here.

If you are unhappy with your hospital discharge, for example if the hospital want to discharge you before you feel that you are ready or if you feel that your discharge assessment was not accurate, you should speak to hospital staff. You can also get advice from the patient advice and liaison service (PALS).

Your GP will also have been informed of your discharge from hospital and may arrange appointments to monitor your recovery. They will also be responsible for giving you repeat prescriptions of your medication if this is required.

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