When you leave hospital, you'll likely recieve support from The Hospital Discharge Hub.
The Hospital Discharge Hub brings together staff from our Adult Social Care team, hospitals, wider health services, and community organisations to help you leave hospital safely.
We work closely with you, your family, and carers to make sure you can access the right information, advice, and support when needed.
When you're ready to go home
As soon as you're medically ready to go home:
- We'll speak to you about about your needs, taking into account your strengths, goals, ideal recovery outcomes, and information from other professionals. This is called a Care Act or Strengths Based Assessment.
- Agree the options available to you to.
- Make sure the right support is in place before you leave hospital.
Assessing your needs
We will focus on:
- What you can do for yourself and what’s important to you.
- What support you already have like help from family, friends, or your community.
- What you might need short-term or longer-term to stay safe, independent and well.
- We won’t just look at the things you find difficult. We will work with you to build on your strengths and find ways to help you get back to living as independently as possible.
If you require care and support, you will receive written information about this. We will also provide some information about potential costs. Paying for adult social care services
If you have complex and ongoing needs, you may be eligible for NHS Continuing Healthcare (CHC) If you're eligible, the NHS will arrange and fund your care. Speak to your care worker or health professional to find out more.
If you can't make decisions for yourself
Some people may not be able to make decisions due to illness, injury, or confusion.
- A mental capacity assessment may be carried out to check if you can understand and decide about your care or discharge plans.
- You can ask someone to support you if you find it hard to speak for yourself or understand things. More about advocacy
- If you have a Lasting Power of Attorney (LPOA) for health and welfare, the named person will be involved in decisions about your care. If you don’t have an LPOA, professionals will make decisions in your best interests, with input from your family or those who know you well. More about Lasting Power of Attorney
- Efforts will always be made to involve you and make sure decisions reflect your wishes, values, and what matters to you.
What happens after you're discharged
We'll speak to you about what options are available which may include:
- No extra help needed: if you don't need new health or social care support, you may go home or return to your care home. We may give you information, advice and guidance about local support or helpful equipment.
- Support at home: you go home with support. This could include visits from care staff at home, equipment such as rails or assistive technology. You might get help from the STARS (Short Term Assessment and Reablement Support) team.
- Recovery in a care home: if you need more help than can safely be provided at home, you may go to a short-term care home for extra support before returning home. We will help you decide what happens next after your recovery.
- Longer-term care needs: if you have complex needs or experience a major change to your health, you may move into a long-term care home or specialist care. A full assessment will be done to make sure you get the right support.
Reviewing your care
After you’ve had time to settle at home or in your new care setting we’ll review your care. This usually takes place after 6 weeks.
Speaking about concerns while you're in hospital
If you have any concerns while you're in hospital, please speak to your ward nurse or care worker.
If you need help after you get home
If things change once you get home and you feel you need more or less help, you can get in touch with us using the contact details on this page.
More support
You can get more support from the following organisations:
- Action Together: works across the borough of Rochdale, providing a range of services to support the voluntary, community, faith, and social enterprise sectors.
- Patient Advice and Liaison Service (PALS): a confidential service that provides help, advice, and information for patients, families, and carers.