Hospital discharge checklist for families

Before discharge: questions to ask the ward

• Has the person been assessed as medically ready to leave, and what is the planned discharge date?
• Which discharge pathway are they on (0, 1, 2 or 3)?
• Has anyone assessed what support they'll need at home, and is that support actually arranged from the first day?
• Have I (as the family carer) been asked whether I am willing and able to help? Has a carer's assessment been offered?
• Will we get a written care and support plan?
• Is any equipment needed (for example a commode, raised toilet seat, hospital bed or walking aid), and who is delivering it?
• Does the home need changes first, such as moving a bed downstairs?
• Should an NHS continuing healthcare checklist be completed?
• Who do we contact if something goes wrong in the first few days?

On the day of discharge

• Transport is booked, and someone will be home when they arrive.
• You have the discharge letter, and a copy has gone to the GP.
• Medicines are supplied, with clear instructions and any changes explained.
• Dressings, continence products and equipment have arrived, and someone knows how to use them.
• Follow-up appointments and community referrals (district nurse, physiotherapy, occupational therapy) are confirmed.
• The heating is on, there is food in, and keys and key-safe codes are sorted.

In the first weeks at home

• Is the support enough? If not, contact the council or the team that arranged it straight away: don't wait for a review.
• Watch for warning signs: new confusion, not eating or drinking, falls, increasing pain or infection.
• Ask for a carer's assessment if you are doing more caring than before.
• Request a benefits check: Attendance Allowance or PIP may now apply.
• If reablement is ending, ask what happens next and whether a longer-term care needs assessment is due.

Your rights during discharge

Under the current national guidance (updated 26 January 2024):

• People should be asked from the outset who they want involved in decisions about their discharge.
• Hospitals must involve patients and unpaid carers (including young carers) in discharge planning as soon as feasible.
• People should be supported to make informed choices, with help from family, advocates or someone with lasting power of attorney where relevant. Where someone has capacity, their decision should generally be respected.
• People with substantial difficulty taking part, and no one to support them, are entitled to an independent advocate.
• If a preferred option isn't available, an alternative suitable for short-term recovery should be offered, but nobody has a right to stay in a hospital bed that is no longer clinically needed.

Discharge pathways explained

What support is free?

Intermediate care, including reablement, arranged by the council is free for up to six weeks. Reablement aims to help people regain skills and confidence at home. After that, ongoing care is subject to a care needs assessment and, for council-funded care, a financial assessment. People whose needs are mainly health needs may qualify for NHS continuing healthcare.

How short-term live-in care can help after hospital

When someone needs more help than a few daily visits (for example in the first weeks after a fall, stroke or operation) a live-in carer can provide support through the day and be there at night. It can sit alongside NHS rehabilitation and community nursing, and it can be arranged as short-term respite while the family works out longer-term plans. For safety, any provider should assess the person before care starts, ideally while they are still on the ward.

For discharge teams and professionals

If you are referring a patient, contact us with the minimum details needed to triage: the person's general location, the type of support needed and the expected discharge date. Please don't send medical records or detailed clinical information through public forms: we'll agree a secure route for anything sensitive.