Coming home from hospital in Lincolnshire

Hospital discharge is where most families first meet the care system, usually with about forty-eight hours’ notice and while someone is being cheerfully told they are ready to go home. It moves faster than anyone expects, and the decisions made in that week shape the following year. This is what the process is, in the order it happens.

What is discharge to assess?

Discharge to assess means people leave hospital as soon as they are medically ready, and their longer term care needs are assessed afterwards, at home, where the picture is more accurate. It exists because assessing someone on a ward tends to overestimate what they need and underestimate what they can do in their own kitchen.

The practical consequence is that the support arriving in the first week is provisional. It is not the final package, and it should not be treated as a decision anyone has made about the long term. Families often assume it is, and either relax too early or panic too early.

What is reablement, and is it really free?

Reablement, also called intermediate care, is short-term support after a hospital stay or an illness that aims to get you back to doing things for yourself. The NHS is clear that it is free, and that it runs for as long as you need it up to a maximum of six weeks.

It is deliberately different in character from ordinary home care. A reablement worker will stand beside someone while they make their own tea rather than making it for them, because the point is to rebuild function rather than substitute for it. It can feel unhelpful to watch. It is usually the right approach.

What happens when the six weeks end?

If support is still needed, it stops being free and becomes ordinary social care, subject to a needs assessment and a financial assessment. This is the moment families describe as falling off a cliff, and it is entirely predictable, which is what makes it worth preparing for.

Start that conversation in week one. Ask the reablement team what they expect the position to be at the end, ask Lincolnshire County Council for a needs assessment on 01522 782155, and get the financial assessment moving. Waiting until week five means a gap, and a gap after a hospital admission is exactly how readmissions happen.

What should you ask before someone leaves the ward?

• What is the diagnosis, and what should we watch for in the first fortnight?
• Which medications have changed, and who is doing the first prescription?
• What equipment has been ordered, and when will it arrive?
• Has a reablement referral been made, and who will make contact?
• Who do we call if things go wrong at the weekend?
• Has a Continuing Healthcare Checklist been considered?

That last one is worth asking explicitly. If health needs are significant, a Continuing Healthcare Checklist should be considered before the social care route is assumed, and hospital discharge is the natural point for it. It is often skipped in the rush.

What are the discharge pathways?

Hospitals in England describe discharge in numbered pathways, and knowing which one is being proposed tells you a great deal about what is coming. They are used across Lincolnshire, so the language on the ward will match this.

Ask which pathway is being planned and why. Families often discover late that pathway 3 has been assumed, when a pathway 1 or 2 with the right support at home would have been possible. It is a much easier conversation to have on the ward than after a placement has been made.

What can you do at home in advance?

Practical preparation makes a large difference to whether the first week holds. Most of it takes an afternoon, and most of it is obvious once someone says it out loud.

1. Move the bed downstairs if stairs are going to be a problem, at least temporarily
2. Clear the routes: rugs, trailing flexes, anything between the chair and the toilet
3. Fill the fridge and check the heating actually works
4. Put a phone, a light and a glass of water within reach of the bed and the chair
5. Write the medication times on one sheet on the kitchen wall
6. Tell a trusted neighbour, so at least one person nearby knows what has happened

Where does a private provider fit?

Usually in one of three places: filling a gap while reablement is arranged, topping up hours that reablement does not cover, or taking over when the six weeks end. Good providers are used to working alongside a reablement team rather than replacing it, and should not be trying to displace free support you are entitled to.

If a provider offers to start immediately without asking whether reablement has been arranged, ask why. The honest answer is that they should be checking. Free support you are entitled to should not be quietly replaced by a package you are paying for, and a provider who does not raise it is either disorganised or hoping you will not notice.

There is one exception worth knowing. Reablement is not available everywhere and capacity varies, particularly across the more rural parts of the county. If nothing has been arranged and the discharge is happening regardless, a short private package while the assessment catches up is a reasonable bridge rather than a failure of the system.

We can often start within twenty-four to forty-eight hours after a discharge, and we would still rather ask first whether you have been offered reablement. If you are in the middle of this now, on a ward, holding a discharge letter and unsure what any of it means, call us. We will talk it through, and if the right answer is to go back to the discharge coordinator and ask two specific questions, we will tell you what they are.