Leaving the hospital

Once the patient is medically stable they may be ready to be discharged from hospital.  What happens next depends on the severity of the injury and the difficulties that remain.  Your involvement in discharge planning is important and you should ask about the options available and the reasons for the choices suggested.  Some patients will be transferred to a different hospital (if they have been in a neurosciences unit at a hospital out of the County of Lincolnshire),because they still need medical input but no longer need to be in the neurosciences unit.

The discharge process.

Before discharge, your relative’s health and social care needs should be assessed by one or more health professionals.  A discharge planning meeting should be held and attended by the relevant professionals.  A copy of the written discharge plan should be sent to the primary carer and the GP. 

Help and support with the discharge process

You can attend the meeting and can bring someone to support you. When patients are discharged from hospital there may be a delay in other services starting and this can be frustrating for patients and carers.  Keeping in contact with the discharge team will help to reassure you.  Talk to the Customer Service Team if you have concerns about the discharge process which you don’t feel has been resolved.

Possible options

When your relative’s health and social care needs have been assessed they should receive one of the following care options:

  • Discharge home - with/without specialist therapy input
  • Specialist neurological rehabilitation – inpatient/outpatient
  • Transfer to a residential care or nursing home

Discharge Home

Discharge home with specialist therapy input - Community Rehabilitation

Your relative may be able to return home straight from hospital. They may then receive rehabilitation as an outpatient either at a local hospital or a separate rehabilitation centre.  Alternatively, therapists from the Community Rehabilitation team may visit them at home.  Whatever the setting, rehabilitation staff will carry out assessments and work out a programme of activities and goals.

If there is a wait for rehabilitation to begin, discuss with the therapists what you can do to help in the short term.

Discharge home without specialist therapy input.

Your relative may have recovered enough to go home without needing further therapy.  Coming home may be a tremendous boost to their morale but it can also be a strain for all the family.  Some patients just want to go home and think “everything will be fine once I am back in my own surroundings”.  You may feel pressurised to take them home even though you don’t feel you’re ready to look after them.  Make sure you have talked through possible difficulties with the staff before you make a decision.

You need to be clear about any adaptations or equipment which might be needed and how these will be provided.  You will also need to know what medications the patient has to take.  The hospital’s Social Worker and Occupational Therapist will be able to talk through these issues and the OT may visit your home to assess any adaptations that will be needed.

Social services

When returning home, your relative should receive a Community Care assessment from the local authority’s social services to assess their needs.  If the eligibility criteria are met, the local authority has a duty to provide support services.  They can help with practical issues such as benefits and housing and can also arrange paid carers to help with washing, dressing, shopping, etc. Social services should also provide support with any concerns about the welfare of your relative, yourself and any children involved. 

Questions to ask if your relative is being discharged home

  • Can you realistically cope?
  • Can they come home for a trial visit?
  • Who will look after them during the day if you need to go back to work?
  • Are any adaptations needed at home?
  • If equipment or adaptations are needed will they be in place in time for your relative’s return?
  • Who do you contact in an emergency?
  • What will happen if you can’t cope?
  • How much input will there be from professionals?
  • What support will be available for the family?

Things to do if your relative is being discharged home

  • Don’t be pressurised into making a decision until you feel able to cope
  • Ask if your relative can come home  for visits initially so you feel confident about coping once they are discharged
  • Think about practicalities
  • Make sure that your relative has had a Continuing Healthcare assessment if this is required,( ask the ward staff if you are unsure) or a Community Care assessment, and that you have received a Carer’s assessment and support is in place before discharge
  • Have contact numbers readily available for advice if there are unforeseen difficulties 
  • Make sure you are familiar with any therapy exercises they are having so that you can continue with these once they are home
  • Make sure you are confident in administering any medications they will need and that you have support with this if necessary
  • Find out what support there will be once they are at home
  • Check that arrangements for follow-up appointments have been made
  • Check that your relative’s GP has been notified

Specialist neurological rehabilitation – inpatient or outpatient

Often following a brain injury, people are left with psychological and physical problems and can be helped by a period of intensive rehabilitation.  This may take place at a specialist in-patient unit, where a structured therapy programme will be put in place.  Alternatively, specialist neurological rehabilitation may be provided as an outpatient for those who are well enough to return home.

It is important that the rehabilitation service is suitable for your relative’s needs.  It is advisable to visit a number of services before making a decision and you can find a UK directory on the United Kingdom Acquired Brain Injury Forum (UKABIF) website (see ‘Sources of support’ for details). You can also contact Headway for a list of Headway Approved Providers.

Questions to ask about specialist neurological rehabilitation

  • What will the assessment process involve?
  • How will the placement be funded?
  • Will there be a long wait for a place?
  • What will the rehabilitation involve?
  • What are the outcomes and goals of the therapy?
  • How long will treatment last?
  • Can I visit before a decision is made?
  • How far away from home is it?
  • What role can the family have in the rehabilitation programme?
  • Will there be family support?
  • What will happen when the rehabilitation ends? Will there be any ongoing support?

Things to do when going into specialist neurological rehabilitation

  • Visit a number of different units before making a decision about an inpatient unit
  • Talk to the management and staff of each unit and try to address any concerns before making a decision
  • Make sure that your relative is as happy as possible with the service, especially if they are to be living in an inpatient unit for a period
  • Find out if there will be a wait when moving between services
  • If there will be a wait, make sure you know where to get support during that time

Nursing/residential care

Following assessment, the discharge team may decide that the person will not benefit from intensive rehabilitation.  However, if complex nursing care is required, looking after the patient at home may be impractical.  In this case, a residential home placement may be most suitable.

Some residential homes provide therapy input, called ‘slow stream rehabilitation’, and some have specialist brain injury services.  This is important because many people still have the potential to make improvements, even years after their injury.

It is advisable to visit a number of units before making a decision.  All residential care services should be registered with the Care Quality Commission (CQC).  You can check whether a particular unit is registered, view inspection reports and receive general information on care services by contacting the CQC (see ‘Sources of support’ for more details).

As well as deciding if the home is appropriate for the patient, the discharge team will also need to establish how the cost of the residential care will be funded.  Funding will be means tested, so your relative may have to contribute some of the costs themselves.  If they have income and savings below a certain threshold then at least some of the costs will be met by the local authority.  If they are entitled to nursing care this should be funded by the NHS and is not means tested.

Even after a placement has been secured your relative’s care needs should be reviewed regularly to identify any changes.

Questions to ask if your relative is going into a residential home

  • Can you visit it before a decision is made?
  • How will the placement be funded?
  • Is the home experienced in the care of people with a brain injury?
  • Will there be rehabilitation input?
  • What rehabilitation professionals will be available?
  • Will a GP visit the home regularly?
  • Will your relative have their own room?
  • What activities are provided?
  • Will any specialist equipment be provided (e.g. wheelchairs, hoists, wet rooms)

Things to do if your relative is going into a nursing home

  • Visit different units and talk to management and staff before making a decision
  • If possible, try to choose a unit with brain injury expertise and specialist rehabilitation input
  • Make sure your relative is as happy as possible with the environment they will be living in
  • Check that the unit is registered with the CQC and view inspection reports