Planning Together and Leaving Hospital

Introduction

This leaflet contains the information you may need when you leave hospital. Please ask about anything you do not understand or if we have not included anything important to you.

What might I expect while in Hospital?

Early Conversations

We will discuss and plan with you, what will be required for you to leave hospital. We will involve your carers, family and/or friends in conversations if you would like them to be included.

If you have been receiving care services before coming into hospital, speak to the ward staff as soon as possible.

Expected date you will leave hospital

You will be given an expected date of discharge, which will be reviewed during your stay. In most cases, you will return home. You might need some additional care, such as help with washing and dressing.

If you live in a care home you will most likely return when safe to do so. If you require complex care this could be into another community settling for example in a residential or Nursing Home.

Why can’t I stay in hospital

Our top priority is to help and support you to leave hospital when the time is right. You will only leave when it is safe to do so.

Staying in hospital when your treatment and care has finished may reduce your independence. You may be less active in hospital and as a result lose muscle strength, this is called deconditioning.

Leaving hospital when you are ready is not only best for you but will ensure a hospital bed is available for someone who is very unwell. Our top priority is to ensure you are in the right place at the right time for the best care possible.

On the day you leave hospital

You will be provided with a discharge summary that will also be sent to your GP. If required, we will arrange medications for you to take away.

Where possible you will be transferred to the Discharge Hub or Transport Hub whilst awaiting medications or transport to leave hospital. The Hub staff will work closely with the ward staff, social services, pharmacy and whoever collects you to ensure your safe departure from the hospital.

Depending on your needs your discharge may take time, please speak with staff regarding any concerns.

Transport home

Where possible, we ask that you make your own arrangements with family, friends, and carers or use a local taxi firm/public transport. Hospital transport is reserved for patients with a clinical need.

Medication

If you have started new medication, you will be given a 1 week supply to take home. Your GP will then prescribe more if required.

You will also find written instructions on the packaging which tells you how to take the medication, including how often and at what time. If you have any questions regarding your medication speak to your Nurse or Ward Pharmacist before you are discharged.

Follow up

If you require a follow-up, outpatient appointment or investigation, we will arrange these and send you a letter or contact you by telephone with the details.

Physiotherapy/Occupational Therapy

If required you will be seen by a member of the Therapy Team. The Therapy Team will assess your mobility and function and advise on rehabilitation requirements both whilst in hospital and for discharge.

The Therapist will play a part in your discharge planning, they will also advise on equipment and adaptations that you may need ready for discharge.

If you feel yourself or a family member would benefit from an assessment by our therapy teams, or if you want to check if a referral has been made, please ask the ward staff to discuss it with you.

Care on discharge

Support in hospital

Your clinical team in hospital will talk to you about your current health and social care needs. They will then talk to you about the most suitable care provision to support you at this time.

The Integrated Discharge Team will then identify with you the support that can meet your needs. Should you or your family/carers wish to speak directly with a member of the Integrated Discharge Team ask the nurse looking after you or contact the team directly on 01642 624731 between 8:30am and 4:30pm.

Choice of care

Whilst we will note any location preferences, care and placements will be offered in terms of availability and ability to meet your individual need and may not be your preferred location.

We would expect you to take up this offer in order not to delay your discharge. This will be a short term arrangement, allowing your time to further improve before any longer term decisions and choices are made.

The discharge team are here to support and answer any questions you may have.

How is the care provision/setting identified?

Your care needs will be discussed with you, your relatives and/or carers, providing you with information about the support that we feel will best meet your needs.

Returning home with care

You may require care in your own home, this will be organised before discharge from hospital. We work closely with Social Services, Community Care, Primary Care and Continuing Health Care.

You may be followed up by a range of different health and social care professionals depending on your presenting needs to assess your longer term health needs.

Package of care

If you are ready to return home but need some additional support, you may go home with a package of care. Once you arrive home, the care provider will work with you to discuss your individual health and social care needs.

Returning home before support is available

If you decide that you would like to leave hospital before the recommended support has been confirmed to begin, it is important that you consider how this might impact you and the people who support you.

It is important to be aware that we may be unable to confirm dates or times when support may be able to start. You may wish to discuss this with your family, friends and the team looking after you in hospital.

Care in a community setting

If you are not able to return home following your stay at Hospital, you can if required be referred for care in an alternative care setting, this could be in a care home. Once discharged your longer term needs will be assessed and you may need to move again.

The type of setting recommended will be based on your individual needs and discussed with you. If you are transferring to a care home, you will receive a follow up from a member of the Community Team either Health or Social Care to discuss your next steps.

Our teams will support your recovery, rehabilitation, and assessment, care planning or short-term support. The team in Hospital will also support you if you have any questions or concerns.

Assessments and financial matters

If you need more care on discharge from hospital this additional care can be provided free for up to 6 weeks to support your recovery. After this time you may be required to contribute financially towards your community care. Which, depending on individual circumstances may be the whole amount.

We know that a hospital environment is not the best place to assess what longer term support you may need, which is why we will look to complete any requested or required assessments with you once you have left hospital. This includes both Care Act Assessments and NHS Continuing Healthcare Assessments.

Contacts

Carer support

If you are a carer or if a family member/friend is a carer there is support available.

Stockton on Tees Adult Care and Support Services – 01642 524494

Stockton on Tees Young Carer Support Service – Eastern Ravens Trust – 01642 678454

Hartlepool Carers Service – 01429 283095 (from 5 years old)

Durham Social Services – Single Point Access – 03000 267979 https://dccarers.org/

Who can I contact?

After you have been discharged, if you have any concerns or need to speak to someone, you can contact your discharging ward with any immediate discharge queries.

If you have concerns regarding ongoing care including community healthcare services call: 01429 522500 for Stockton and Hartlepool residents.

Other Contacts

Durham residents Social Care – Direct call 03000 267979

First Contact Stockton – 01642 528866

Hartlepool Social Care – duty on 01429 803100

Comments, concerns, compliments or complaints

Patient Experience Team (PET)

We are continually trying to improve the services we provide. We want to know what we’re doing well or if there’s anything which we can improve, that’s why the Patient Experience Team (PET) is here to help. Our Patient Experience Team is here to try to resolve your concerns as quickly as possible. The office is based on the ground floor at the University Hospital of North Tees if you wish to discuss concerns in person. If you would like to contact or request a copy of our PET leaflet, please contact:

Telephone: 01642 624719

Freephone: 0800 092 0084

Opening hours: Monday to Friday, 9:30am to 4:00pm

Email: [email protected]

Out of hours

Out of hours if you wish to speak to a senior member of Trust staff, please contact the hospital switchboard who will bleep the appropriate person.

Telephone: 01642 617617

Data protection and use of patient information

The Trust has developed Data Protection policies in accordance with Data Protection Legislation (UK General Data Protection Regulations and Data Protection Act 2018) and the Freedom of Information Act 2000. All of our staff respect these policies and confidentiality is adhered to at all times. If you require further information on how we process your information please see our Privacy Notices.

Telephone: 01642 383551

Email: [email protected]

Leaflet feedback

This leaflet has been produced in partnership with patients and carers. All patient leaflets are regularly reviewed, and any suggestions you have as to how it may be improved are extremely valuable. Please write to the Clinical Governance team, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, TS19 8PE or:

Email: [email protected]