Leaving Hospital?

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 response .

Not only does this help ensure the best result for the client but also provides you with sufficient notice to review the client’s assets and establish what arrangements need to made for funding care and avoiding the frustrating position of not having access to  funds to pay for care.

The transition to home, rehabilitation or a care setting is critical to the ongoing health and wellbeing of your client. Clients will often be moved using a hospital discharge pathway process which as a process is focused on transitioning patients out of the hospital and relieving bed pressures. These processes can often lengthen the transition from hospital to home and self-funding clients can be disadvantaged. Your clients have an advantage if they fund their own care, but without the empowering specialist professional support from an independent agency, they may struggle to assert their 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 the client’s 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 the client continues 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 the clients 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 clients return home.
  • Ensuring all equipment and aides are installed in the house and that the client is informed on how to use them. Ensuring that the home is heated and full functional before discharge.
  • Tracking your client’s progress and providing updates.
  • Weekly check (or more frequently if required) on the client and reporting back to deputy with recommendations.
Leaving hospital