Having a loved one in hospital can be an anxious and exhausting time. When discussions about discharge begin, many families feel overwhelmed by the terminology, the number of professionals involved, and the uncertainty about what will happen next.
This guide is written for families and friends of older or frail patients in hospital, particularly those being discharged from hospitals in Bournemouth, Poole, Southampton, and across Hampshire, Dorset, and Wiltshire. It is designed to be warm, reassuring, and practical—helping you understand what discharge planning is, why it starts early, and how you can support your loved one safely through this transition.
✓ Key Takeaways
- Discharge does not mean fully recovered—it means your loved one is medically stable and can continue recovering outside hospital.
- Planning starts from admission, so share information about their usual abilities early to help the team plan ahead.
- Understanding funding routes and care pathways helps you advocate effectively for the right level of support.
In This Article
What Is Discharge Planning?
Discharge planning is the process of making sure that when someone leaves hospital, they are going to a safe and appropriate place with the right level of hospital discharge support in place. Hospitals have a duty of care that extends beyond the ward doors—they cannot simply send someone home without ensuring care, equipment, therapy, and follow-up arrangements are appropriate.
Important: Discharge does not mean that someone is fully recovered. It means they are medically stable, and that further recovery and hospital discharge rehabilitation can continue outside the acute hospital environment.
When Does Discharge Planning Start?
Discharge planning starts from the moment someone is admitted to hospital. Early in the admission, staff gather information about the patient’s usual mobility, function, cognition, existing care arrangements, and home environment.
This information allows hospital teams to identify any changes during the stay and plan ahead. If needs are unchanged, existing care can often restart quickly. If needs have increased, therapy teams can assess and plan additional support before discharge.
Who Is Involved?
Discharge planning is a team effort involving ward staff, discharge coordinators, physiotherapists, occupational therapists, social services, community care agencies, and district nurses. Families play a crucial role in this process.
How Families Can Help
Families can support discharge planning by:
- ✓ Providing a clear main and secondary contact for the ward team
- ✓ Sharing accurate information about pre-admission abilities and daily routines
- ✓ Informing staff about Power of Attorney where relevant
- ✓ Speaking with therapists and discharge coordinators early in the admission
- ✓ Preparing the home environment in advance
Supporting Recovery While in Hospital
Families can help prevent hospital-acquired deconditioning by encouraging movement, sitting out of bed, walking where appropriate, and maintaining engagement and routine. Even small amounts of activity can make a significant difference to recovery.
Preparing the Home
Early preparation may include:
- ✓ Decluttering walkways and removing trip hazards such as loose rugs
- ✓ Making space for equipment like commodes or walking frames
- ✓ Stocking the fridge and freezer with easy-to-prepare meals
- ✓ Turning the heating on before they arrive home
- ✓ Ensuring good lighting, particularly on stairs and in hallways
A calm, safe environment helps reduce anxiety and supports a smoother transition when returning home after a hospital stay.
Equipment
The NHS provides essential equipment that is necessary for a safe discharge home. This might include mobility aids, commodes, urine bottles, bed levers, pressure relieving equipment, and more.
Families can help by transporting this equipment home, fitting it (if the occupational therapist permits), or being present to receive a delivery.
💡 Tip: If you are considering purchasing equipment privately, speak to an occupational therapist first to avoid unnecessary expense and to ensure anything you buy is fit for purpose.
Transport Home
Families are encouraged to collect loved ones where possible. Consider how mobile your loved one is, how low (or high) your car seat is, and whether the person transporting them will be able to assist them out of the car once they arrive home.
Hospitals can arrange wheelchair or stretcher transport if needed. If your loved one is using hospital transport for discharge, be aware that the discharge day might be long—being there to welcome someone home is invaluable. They will be tired, excited, and possibly overwhelmed.
Care Packages and Funding
The therapy team will assess your loved one and determine what level of care they will need when they first return home.
Reablement (Short-Term Funded Care)
If your loved one has never had care before, the initial few weeks of care (usually up to a maximum of six) may be funded. This is frequently called Reablement, or may be provided by the hospital’s interim care team. The aim is to help people regain independence rather than simply “do things for them.”
Established Care Needs
Where a patient has established long-term care needs, it is less likely that funding will be available on discharge, particularly if they had a package of care before they were admitted to hospital.
Self-Funding Thresholds
Funding for longer-term home care is means tested. As a general rule:
This is a simplified guide—other income (such as pensions) and property ownership can affect eligibility. The social worker assigned to your loved one can explain the financial assessment process in more detail.
Rehabilitation Pathways
The other discharge route is via a rehabilitation pathway. Where someone had a good level of independence prior to admission and they have clear goals for rehabilitation, the therapy team may refer the patient to:
- An intermediate care team for daily care and rehabilitation at home, or
- A rehabilitation bed for in-patient rehabilitation at a community hospital
The physiotherapists and occupational therapists will determine eligibility for these pathways and make the necessary arrangements if the patient is in agreement.
What If You Have Concerns?
Feeling that your loved one is not ready to leave hospital is very common. In my experience, families tend to fall into two groups: those who are desperate to get their loved one out of hospital and feel they are “stuck” there, and those who feel their loved one really is not ready to leave because they are not better yet.
The guiding principle of discharge planning is to go “home first” with the right level of care and support. Going into a care home or nursing home before someone has attempted being at home with a package of care is quite rare and generally avoided unless necessary.
Night-Time Needs
When considering whether someone will be safe to go home (or may need a further stay in an in-patient unit), the therapists will consider what someone’s needs are around the clock, particularly at night.
If night-time needs are manageable, home is usually appropriate with support. However, if the patient has significant night-time needs—such as needing help to get up for the toilet frequently, position changes for pressure area care, or wandering unsafely (in the case of someone living with dementia)—other options may be considered:
- Family support (staying overnight)
- Paying privately for a sleep-in carer or a waking night carer
- Private respite in a care home to allow more time to recuperate
Follow-Up Care After Discharge
Care packages often start quickly after discharge. However, community therapy waiting lists can be several months. Many families choose private physiotherapy or occupational therapy to bridge this gap and ensure rehabilitation continues without delay.
Who to Contact After Discharge
Medical Concerns
Contact your GP, call 111, or dial 999 if urgent
Mobility or Daily Living
Contact community therapy teams or your care agency
Private Rehabilitation
Contact us for home visits across Hampshire, Dorset & Wiltshire
The Role of Occupational Therapy
Occupational therapists are a somewhat misunderstood profession, but their knowledge and skills are invaluable. They are sadly often known only for doing home visits and issuing equipment during discharge planning—but their expertise extends far beyond this.
Occupational therapists can support and enable people to get back to doing their daily activities, building confidence, and establishing meaningful routines. They work alongside physiotherapists to reduce long-term care needs and help people regain independence.
Medical Disclaimer: The information in this article is intended for general educational purposes only and should not be considered a substitute for a personalised assessment from a qualified healthcare professional. Please consult with a therapist or your GP for advice tailored to your specific situation.
In Summary
Discharge planning works best when families are involved early, communication is open, and expectations are clear. With the right support, patients can continue their recovery safely and with dignity at home.
If you have a loved one being discharged from hospital in Bournemouth, Poole, Southampton, or anywhere else in Hampshire, Dorset, or Wiltshire, and you would like to discuss private physiotherapy or occupational therapy to support their recovery at home, please do not hesitate to get in touch. I am always happy to have a chat and offer guidance—even if you are not sure whether our services are right for you.
Worried About a Pending Discharge?
We can often visit within 48 hours of returning home. Call Naomi for free, no-obligation advice about supporting your loved one’s recovery.
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