Care after hospital discharge: who arranges what?

Explain how the person lived before admission and what has changed. Include stairs, bathroom access, who lives at home, existing care visits and help relatives can actually provide. A discharge plan built around a relative being available all day will not work if that relative has a job or their own care needs.

Ask who is coordinating discharge and how to contact them. The person should be involved in decisions, with relatives or carers involved appropriately and with permission. The NHS guide to planning to leave hospital describes planning during a stay, including the support, equipment and practical arrangements required.

If something in the proposed arrangement is unclear or unworkable, explain it early and specifically. “There is nobody to let the evening carer in” identifies a problem that can be resolved. Ask the team to record the concern and tell you who will address it. A proposed discharge date is useful, but it does not replace the details of the plan.

Some people return home without extra care. Others need short term support at home, rehabilitation or a temporary stay somewhere with support. For some, a longer term care arrangement will be necessary. These are different outcomes, so ask whether the proposed arrangement is for recovery, assessment or ongoing care.

England's hospital discharge guidance supports assessing longer term needs after recovery where appropriate. A person's ability shortly after an illness or operation may not be their settled level of need. This does not mean concerns should be ignored until later. It means the immediate plan and the later assessment need their own responsibilities and dates.

If a temporary care home stay is proposed, ask its purpose, expected review point, who pays and what determines the next move. Do not assume that accepting a temporary placement settles the permanent decision. Equally, do not assume the person can stay in an acute hospital bed until every preferred longer term option is available. Discuss realistic, suitable alternatives with the team.

Complete this with the discharge team. A name, telephone number and confirmed time are more useful than “the hospital will sort it”. The responsible organisation varies with local arrangements and the person's needs.

If a referral has been sent but not accepted, record that distinction. Ask who will check acceptance and what happens if the expected service does not start.

Think through arrival, the first meal, the toilet, getting into bed and the next morning. Ask what the person can safely manage and where support is required. Confirm that the agreed help covers the actual time of need. A morning visit tomorrow does not answer who is helping someone this evening.

Check keys, heating, food, a working telephone and a way to reach help. Confirm that essential equipment is ready and that the people expected to use it understand the instructions. Ask the hospital team about medicines changes and who will explain anything unclear. Do not improvise a clinical task or moving technique because someone has arrived home without a clear handover.

If a care agency was involved before admission, ask who has told it about the return home and changed needs. A previous package may need reassessment. Use our guide to starting home care to check the provider handover and first visits. The family should know who to call if the agreed visit fails to happen.

Hospital discharge is not a single funding category. NHS treatment, assessed recovery support and ongoing social care can have different rules. Ask the team to identify the actual service being offered, who funds it, whether there is a charge and when the arrangement will be reviewed.

The NHS explains that intermediate care or reablement is free for the period it is assessed as needed, often one or two weeks and usually up to six weeks. This is not a promise that everyone leaving hospital gets six weeks of free home care or a free care home stay. Our reablement and intermediate care guide separates recovery support from continuing help.

Longer term social care may involve a council needs assessment and financial assessment. Some people may need consideration for NHS continuing healthcare. Ask about the applicable route without assuming an NHS hospital admission makes every subsequent care cost an NHS responsibility. Get any proposed private arrangement and its charges in writing before agreeing it.

Before a short term service finishes, ask what progress has been made, what help remains necessary and who will arrange it. Record the final visit date and the first date of the next arrangement. These two dates should be checked together, particularly when different organisations are involved.

If the person needs ongoing care, ask which team is undertaking the care needs assessment and who will explain the financial assessment. Share what has happened since discharge, including tasks still requiring help and what the person can now do independently. Recovery observations can make the longer term plan more accurate.

Relatives providing care can ask about a carer's assessment. Be clear if support that was possible for the first few days cannot continue indefinitely. “We managed this week” is not the same as agreeing to provide that help permanently. Ask for a copy of the ongoing plan and a named contact before the short term team closes its involvement.

While the person is in hospital, raise concerns with the ward or discharge coordinator and ask for a response. If you cannot resolve them, ask about the hospital's Patient Advice and Liaison Service. The NHS discharge guidance identifies ways to raise concerns about the planned discharge.

After the person leaves, use the contact relevant to the gap: the care provider for a missed visit, the equipment service for delivery or setup, or the clinical team for a treatment question. If responsibility is unclear, contact the discharge team or named recovery coordinator and explain exactly what was expected and has not happened.

Keep a brief record of who you spoke to, the action promised and the time it is due. A routine complaint will not resolve an urgent safety problem quickly enough. Use emergency services for an immediate emergency and appropriate urgent clinical advice for a new health concern. Continue pursuing the practical care arrangement with the responsible team.

Ask the home to explain its reason in writing and tell the hospital discharge team. Clarify whether the home is waiting for a reassessment or says it can no longer meet the person's needs. Our guide to a care home refusing a return after hospital covers the questions to ask, planning the next arrangement and checking fees.