Complex care and hospital discharge team

This guidance provides information on the services available to you when you are discharged from hospital. It also describes how we can assist in arranging services and other suitable support packages.

Who are the Complex Care and Hospital Discharge team?

We are a small team located at the General Hospital, made up of social workers and care managers.

We are employed by the council and are part of the Health and community care division.

We aim to reduce you length of stay in hospital by setting up support networks for you and ensuring you receive the correct level of care when you are discharged.

How can the Complex Care and Hospital Discharge team help me?

If you are aged over 18 and are an inpatient at the General, Princess Anne or Royal South Hants hospital, we will be able to help you.

You will be referred to us within 24 hours of being admitted to hospital, if the hospital staff identify that you will need help.

We can arrange care that you may need after you have been discharged from hospital including:

  • Telling you about other organisations that can help in areas such as housing, benefits or counselling
  • Referring you to specialist services such as alcohol and drug misuse/dependency centres
  • Organising services such as meal provision or help with washing and dressing
  • Providing information if you need 24 hour care
  • Offering support to your family

Assessment

A team member will visit you on your ward to carry out your assessment. This will happen when you are approaching your discharge date.

We will discuss any services or care you are already receiving from health and community care or any other support networks that are in place, such as family or friends.

We will also ask you to think about your needs when you return home.

The assessment will take about 30 minutes and will focus on exploring ways of working together to meet your needs.

You are welcome to involve family members in the discussion. We may talk to your family or friends separately.

We will also talk to your ward nurse and your occupational therapist or physiotherapist if involved.

In consultation with you, we will agree what your needs are and how to meet them.

What happens after the assessment?

  • Your care manager will let you know if you are eligible to use our services
  • Based on your assessment and your eligibility, we will put together a care plan for you. We will give you the plan while you are still in hospital or post it to you shortly after you are discharged
  • If you don’t meet our eligibility criteria, we will give you an information pack, which lists other organisations that may be able to help you, it also provides general information
  • Once you have been discharged from hospital other health and community care teams will care for you

Rehabilitation

Sometimes the ward, or our team will identify a need for rehabilitation, either in the community or another hospital, in which case the ward can make a referral. This will be discussed during your assessment.

Following your departure from hospital we will encourage the help and support of your family and friends, along with the services set up by our team.

Follow on care

Here are examples of the care you may receive

Rehabilitation – A carer may come to your home to carry out a programme such as rehabilitation. A professional may help you to use any new aids and adaptations that have been installed in your home.

Meal provision – There are several companies that can deliver fresh or frozen meals to your door. There is a set price for each meal.

Welcome home scheme – This is a scheme that can provide you with short-term support whilst you are recuperating. A carer will call at your home for up to two weeks. They can help with shopping, cleaning, personal care and other similar tasks. You don’t need to be living alone to receive this support. There is a small charge for this service.

Existing care packages – You may already have a care package in place and we can help to ensure that this is still suitable for you once you have left hospital.

Paying for services

Some of our services are chargeable and this will be discussed with you during your assessment.

Further information

For further information please contact

Complex Care and Hospital Discharge Team
Level B, West Wing, Southampton General Hospital, Tremona Road
Southampton
SO16 6YD
023 8120 6758
023 8120 4120