Local authority social workers become involved only when a patient is deemed as medically fit for discharge, but why wait? Clear Guide advocate becoming involved at the point of admission and use their specialist knowledge of the hospital setting to work alongside health professionals to achieve the best possible outcomes and ensuring decisions about discharge services are given consideration rather than an urgent reactive response.
The transition to home, rehabilitation or a care setting is critical to the ongoing health and wellbeing of your loved one. Patients will often be moved using a hospital discharge pathway process. You have an advantage if you fund your own care, but without the empowering specialist professional support from an independent agency, you may struggle to assert your rights and wishes. A successful discharge can reduce readmission, increase recovery, maintain or promote independence and decrease costs.
Our social workers are ex-local authority hospital social care professionals, who have extensive experience and knowledge of working in acute hospitals, community hospitals, rehabilitation units and wards. Our social workers have worked in hospital Discharge Liaison Teams and understand how to source the appropriate services and plan timely discharges while working with the multi-disciplinary team to advocate on your behalf and gain the best possible outcome.
How We Can Help
Clear Guide will ensure the following:
- Appropriate Mental Capacity Assessment is completed.
- Coordinate a Best Interests meeting with appropriate professionals, family and representatives.
- Identify health and care needs – this includes healthcare, domestic and emotional needs.
- Checking medication and ensuring you continue to have access to this once discharged.
- Complete the NHS Continuing Healthcare Checklist.
- Consideration as to whether benefits need to be reviewed.
- Undertake a search for an appropriate care setting, considering your care needs and personality.
- If returning home, ensuring a care agency and possibly a domestic agency is instructed.
- Dealing with practical issues such as transport home, locating house keys, collecting medication, ensuring supply of continence products, food shopping and informing GP and local authority professionals of your return home.
- Ensuring all equipment and aides are installed in the house and that you are informed on how to use them. Ensuring that the home is heated and full functional before discharge.
- Tracking your progress and providing updates.
- Weekly checks.