This factsheet aims to provide information to assist those returning home after a stay in hospital, particularly those who may require long-term care perhaps relating to some form of temporary or permanent disability. 

WHILE IN HOSPITAL
Each hospital has to have set procedures to plan for when you leave hospital.  As soon as you are admitted, hospital staff should set these procedures in motion. 

While in hospital, a ward based Care Co-ordinator, usually a nurse, will be responsible for organising and planning your care and discharge home (during your discharge process it may be more appropriate for a therapist or social worker to take over this role).  They can give you information on the hospital's discharge procedure and what happens if you need care after leaving hospital.  You should not be discharged until the appropriate care and support is in place. 

The hospital should inform your GP of your admission, and, on admission, the hospital should start making arrangements for your discharge so that a written discharge plan can be provided for your return home. This plan should give information on who to talk to about any equipment, aids and adaptations that you may need and information on who to contact - for example GP, District Nurse, Social Worker - after returning home. The hospital should also arrange your transport home if necessary. 

If the hospital or social services think you would benefit, you may be offered rehabilitation before returning home.  This might involve special exercises or practice in everyday tasks.  Treatment or advice might be given by Physiotherapists, Occupational Therapists  or Speech Therapists.  You may even spend time at a Rehabilitation Unit. 

ASSESSMENT OF CARE NEEDS
Most people leaving hospital may not require any further care or support, but if on discharge from hospital, it has been identified that you need care or support, then an overall assessment of your needs will take place. The NHS has a statutory responsibility, under the Community Care Delayed Discharges Act 2003, to make a referral to social services if there is an identified need for support once your discharge has been planned. You must be made aware of this and give your permission for the referral to be made. You have the right to an assessment regardless of whether you or your Local Authority will be funding any services you need.  

This assessment will be carried out by a social worker or care manager and will include information provided by other health professionals that have been involved with your care. You and, usually, your closest carers and family will be included in the plan so that you can give your views and express your wishes. Such involvement should help you to understand and agree with the outcome of the assessment. If you are eligible for care/support, the information provided will be used to form your 'Care Plan'. This plan will describe your assessed care needs when you leave hospital, who will meet your needs, how and where they will be met. The care plan and the services identified to meet your needs should be in place prior to your discharge from hospital. A relative, friend or neighbour who will be providing you with a lot of care or support is also entitled to an assessment of their needs as a carer.  They do not have to live with you to get this. 

SHORT TERM ENABLEMENT PROGRAMME (STEPS)
Once you return home you may need to regain your confidence and independence with every day tasks. Doncaster Local Authority offer a short term service that aims to provide you with the support you may need when you return home from hospital. Through this service you will receive support to enable you to:

• Prepare your meals
• Improve your mobility
• Bathe and manage your personal care needs
• Carry out domestic routines within your home
• Keep safe and secure within your community 

This service may be arranged for you via your assessment.

CONTINUING CARE
Continuing care describes a number of specialist services, which include health and social care, respite care, rehabilitation services and continuing in-patient care under a hospital consultant. It is the hospital's responsibility, before your discharge from hospital, to ensure that proper arrangements are in place for your return home and for any continuing health care which may be necessary. 

NHS CONTINUING HEALTH CARE
This is a package of services funded and arranged by the NHS for those that have ongoing health needs that do not require care in an NHS acute hospital. Anyone can qualify for NHS continuing healthcare funding if their needs satisfy the eligibility criteria. 

SOCIAL CARE
The provision of social care services can help you live as independently and as safely as possible.  There are a wide range of services available. Support can include, help with care in your home, any equipment and adaptations you may need, to being accompanied on leisure and social activities. Some services may be provided free of charge but, dependent on your financial assessment you may be required to make a contribution to your care.