From Failed Discharge to Independent Living

When a hospital discharge goes wrong, it can feel like the beginning of a permanent decline. For this patient and her family, a failed discharge home led to admission to a respite care home — and real uncertainty about whether she would ever return to living independently.

The Situation

After being discharged from hospital, she was simply not able to manage at home. She was readmitted to a respite care home where, while safe and supported, everyday life ground to a halt. Meals were brought to her. Hot drinks were made for her. Personal care was provided for her. The care home staff were doing their jobs well, but the effect was that she had no reason — and no opportunity — to do anything for herself.

Our occupational therapist identified the problem immediately during the initial assessment. There was also a specific shoulder issue that needed specialist physiotherapy input, which fell outside the OT’s scope of practice. The decision was clear: this patient needed a joint OT and physiotherapy approach to give her the best chance of getting home.

What We Did

Together, the OT and physiotherapist built a programme that addressed both her physical needs and her everyday living skills. While the physiotherapist worked on her shoulder rehabilitation and mobility, the OT focused on the practical tasks she would need to master before going home:

• Personal care — progressing from assisted washing to fully independent showering
• Kitchen tasks — making her own hot drinks and managing simple meal preparation
• Home equipment — identifying and arranging the right aids and adaptations for her property
• Careline service — setting up a personal alarm system so she could feel safe living alone

The Joint Approach

What made the real difference was how closely the two disciplines worked together — and how they collaborated with the care home staff. Rather than the care home continuing to do everything for her, we agreed a graded approach with the team. For example, instead of a carer actively helping her to shower, a member of staff would simply stand by the door to offer reassurance. That small shift — from doing it for her to being there while she did it herself — was transformative.

“The care home environment is safe and people are looked after, but it can inadvertently disable someone. Everything is done for them, so they stop doing it for themselves. Our job was to reverse that — to give her back the confidence and ability to manage on her own.”

The OT’s goals were met first. The physiotherapist continued visiting to address the ongoing physical rehabilitation, ensuring her mobility and shoulder function were strong enough to sustain independent living long-term. She also expressed a desire to return to driving, and her family planned to support her in rebuilding that confidence once she was settled at home.

The Outcome

After approximately eight weeks of joint rehabilitation, she returned home from respite care. The most remarkable part? She went home with no care package whatsoever — fully independent, managing her own personal care, her own household tasks, and her own daily routine.

For someone who had experienced a failed hospital discharge and was living in a care home with everything done for her, this was a complete turnaround.

Why This Matters

A failed discharge from hospital can be deeply unsettling for families. It can feel like a turning point — the moment a loved one’s independence slips away for good. But it does not have to be permanent.

With the right rehabilitation, the right expertise, and a clear plan, many people can rebuild their independence and return home. This case shows what is possible when occupational therapy and physiotherapy work hand in hand — not just treating physical problems, but addressing the full picture of what someone needs to live well at home.

If your relative has experienced a failed discharge or is currently in respite care, it is worth asking whether a structured rehabilitation programme could help them get back to the life they want.