What to expect when you leave hospital

Someone will get in touch with you (either by phone or face-to-face on the ward) about your care and support needs and where you might go when you leave hospital. If you would like a family member, friend or carer to be included in this discussion, please let them know

In most cases, you will return home. You might need some additional care to help you in your recovery, or practical support such as help with shopping.

If you are a care home resident, you will most likely return to your care home. If you require more complex care and support this might be in a different place, such as a nursing home.

In hospital, the discharge hub help coordinate the teams that will deliver your care and support needs when you leave hospital. Different teams (made up of health and social care staff) have their own areas of knowledge and expertise. Discharge staff will put the right team in touch with you. Some team names you might hear are:

• Complex Care and Hospital Discharge - a small team located at the General Hospital, made up of social workers and care managers, and are part of the council Health and community care division
• Urgent Response Team - An integrated Health and Social Care Service , responding to adults with a health crisis in Southampton to avoid hospital admissions and assist with hospital discharges
• Community Independence Service (CIS) - The CIS provides a wide range of rehabilitation, reablement and social care assessment and support

When you no longer need hospital care and it is felt that it is safe to do so, you will be discharged. You will get the care and support you need in the best possible place to support your recovery.

There are a range of short-term services designed to support your recovery after you leave hospital, and we can help you plan for any possible future care needs.

Before you leave hospital, the discharge team staff will make a referral to the appropriate team. A member of the team will then contact you (or a friend or family member who you have asked to act on your behalf) to begin their own initial assessment so they can start their service when you leave hospital. They will also chat with you to see what you would like to achieve to increase your independence and will work with you on a plan to help you achieve this.

Once you have left hospital, a member of the social work team will be assigned to you as soon as possible. They will arrange a time to visit you to carry out an assessment of your care needs.

Some people may be eligible for NHS Continuing Healthcare. Continuing Healthcare is a package of ongoing care arranged and funded solely by the NHS for a relatively small number of individuals (with high levels of need) who are found to have a ‘primary health need’. Such care is given to an individual aged more than 18 years old to meet their health and social care needs that have arisen because of disability, accident, or illness.

We will send you information before the assessment to help you to prepare for the meeting. This will explain more about the assessment and the kind of questions you will be asked.

All these short-term care and reablement council services are free of charge. Depending on your needs, and the progress you make, these services can last for a few days up to a few weeks (depending on the service offered) which considers your needs and the progress you make.

The options on this page cover you leaving hospital and continuing your period of recovery. If you have ongoing care and support needs which are assessed as being eligible for help from the council, we will work with you to develop a personal support plan.

There are many different options we will look at with you. This could include what you can do for yourself, help from family and friends, access to community facilities or support from voluntary services. We might also suggest equipment or adaptations to your home. Your support plan will make the most of what you can do with the help you have around you.

If you are not eligible for services from the council, we will give you information and advice about how to access care and support services for yourself. You can find information and services to manage your own care needs and to stay independent on our self-assessment tool:

Care self-assessment

Occasionally some people might be eligible for NHS Continuing Healthcare funding.

If you are eligible for help from the Council and you require formal services, such as residential care or a paid carer coming into your home, the social worker will arrange for you to have a financial assessment, if you haven’t had one previously. This is to determine how your long-term care will be funded.

Depending on your financial circumstances, you may need to pay some or all of the cost of your care and support.  You will be given more information about this at the appropriate time.

In line with your care and support needs, the health and social care team will choose the most appropriate place for you to continue your recovery. If you don’t want to accept the care offered, you will still have to leave hospital and arrange your own care or support once you have been discharged.