Coming Home from Ipswich Hospital: Discharge to Assess Explained

If you are with a relative or loved one at Ipswich Hospital and have been told they are approaching discharge, you may hear terms such as 'medically optimised', 'Home First', 'Transfer of Care', 'Pathway 1' and 'reablement' during discussions with different members of staff. These terms describe different parts of the discharge process, but it is not always immediately clear how they relate to one another or what they mean for the arrangements at home.

Discharge to Assess at Ipswich Hopsital is intended to support people to leave hospital once they no longer require an acute hosspital bed, with longer-term care and support needs assessed in the appropriate setting. This guide explains how the process works, the different pathways and what they mean, the teams involved in coordinating discharge, the questions families may wish to ask on the ward, and how A Class Care can support discharge.

Discharge to Assess at Ipswich: The Three Pathways and Why Home First Comes First

Discharge to Assess means that a person leaves hospital once they are medically ready, with their longer-term care and support needs assessed after discharge in the most appropriate setting. In the Suffolk area, the process is generally organised around three pathways. The pathway identified for a person helps determine the type of support and assessment that follows.

Pathway 1: home with support
The person returns to their own home with appropriate care, equipment and support arranged as part of the discharge process. Their longer-term needs are then assessed in their home environment over the following days or weeks.

This reflects Suffolk’s Home First approach, which aims to support people to recover and be assessed at home where this can be done safely and appropriately. A person’s abilities and support needs may differ between a hospital ward and their usual home environment, and assessment at home can provide a clearer understanding of the support required.

Many people discharged through Pathway 1 require temporary or ongoing care at home, and this is the pathway on which we most commonly provide support at A Class Care.

Pathway 2: a short stay in a community bed
For a person who is medically ready to leave hospital but cannot yet return safely, even with support, they are likely to be put on Pathway 2. It usually involves a period of rehabilitation or assessment in a community or intermediate-care bed. The intention is generally to support rehabilitation and, where possible, a later return home.

Where this pathway is proposed, families may wish to ask about the expected purpose and duration of the placement, the rehabilitation or assessment planned and what would need to happen before a return home could be considered.

Pathway 3: assessment of longer-term care needs.
Pathway 3 is generally used where a person’s needs indicate that a return home is unlikely to be appropriate and where longer-term residential or nursing care may need to be considered. Assessment of those longer-term takes place outside the acute hospital ward.

The pathway is based on an assessment of the person’s needs and circumstances. The fact that someone currently requires a high level of support does not, by itself, determine which pathway will apply.

Whichever pathway is being considered, discharge arrangements at Ipswich Hospital are coordinated through the Transfer of Care Hub. The Hub brings together the health, social care and community services involved in supporting discharge. Depending on the person’s needs, this may include discharge coordinators, social care professionals, reablement services and other community teams. A case manager may be involved where coordination across services is required.

The purpose of the discharge process is to identify the support needed after a person leaves hospital, whilst avoiding unnecessary delays in an acute hospital bed once hospital treatment is no longer required.

Eight Questions to Ask on the Ward Today

Discharge planning at Ipswich moves quickly once a person is close to being medically ready, and much of the useful information is held by different members of the team. You can ask your nurse in charge or discharge coordinator these questions to help establish where you are in the process.

1. What is the expected date of discharge?

It is set early and reviewed as the hopsital stay goes on. If nobody has mentioned one, ask for it.

2. Has my relative been referred to the Transfer of Care Hub?

Ask the ward team or discharge coodinator whether a referral has been made. If it has, ask who is coordinating your relative's discharge and what the next steps are. If it hasn't, ask whether a referral would be appropriate to help arrange any care or support they may need after leaving hospital.

3. Which discharge pathway are they on?

The answer decides whether the assessment happens at home or in a bed elsewhere, and what future care is likely to include.

4. Has occupational therapy or physiotherapy assessed them?

Ask the ward team whether your relative needs an occupational therapy or physiotherapy assessment and whether it has taken place. If it has, ask what was recommended to help them manage safely at home, including equipment, help with moving around or everyday tasks. If an assessment is needed, ask when it is expected to happen.

5. Is any equipment being ordered?

Ask the ward team whether any equipment has been recommended or ordered for your relative. Find out what it is, where it will go in the home, and who will arrange delivery and installation. Ask whether it needs to be in place before your relative comes home and who will explain how to use it safely.

6. Is reablement being considered?

Ask the discharge team whether your relative could benefit from reablement which is short-term support to rebuild confidence and independence with everyday tasks. If it is being considered, ask who would provide it, when it would start, how long it might last and whether there would be any charge. Ask what support could follow if your relative still needs help afterwards.

7. Is there anything currently preventing discharge?

Medication, transport, equipment and confirmation of care are the usual reasons for delay. Knowing which one applies tells you what can be chased.

8. Can a private care provider assess them on the ward?

Normally yes, with the person's consent, but you will still need to ask the hospital discharge team.

'Clinically Fit' is Not the Same as Leaving Today

Being clinically fit for discharge means that a person no longer requires acute hospital treatment. It does not necessarily mean that they will leave hospital on the same day. At Ipswich hospital, as at many other acute hospitals, a number of discharge arrangements may still need to be completed after the clinical decision has been made.

Before the person can leave hospital safely, the following arrangements may still need to be completed:

• Take-home medication: This may need to be dispensed by the hospital pharmacy.
• Therapy recommendations: Occupational therapy or physiotherapy assessments may still be required.
• Equipment: Essential items may need to be delivered or installed at home.
• Care arrangements: The required support must be confirmed and in place.
• Transport: Suitable transport may need to be arranged.

Non-emergency patient transport is available to people who meet the criteria:

• If your medical condition, mobility needs or impairments prevent you from safely travelling to a healthcare appointment by other means of transport.
• If a child is travelling with their parent or guardian.
• If you receive regular treatments for medical conditions such as cancer.

For Ipswich Hospital, it is provided by Health Transportation Group (HTG) and can be booked by calling 01245 951205.

If a person is moved from their ward to the discharge lounge whilst final arrangements are completed, this should not necessarily be interpreted as confirmation that they are leaving the hospital immediately.

What a Ward Assessment at Ipswich Hospital Involves

When we recieve an enquiry about someone at Ipswich Hospital, we allocate a Service Manager to the case. Where appropriate, the care assessment can be completed whilst the person is still in hospital rather than waiting until they have returned home.

The assessment looks at the person's current care and support needs, including:

• Mobility and transfers: how the person moves, transfers and whether support from one or two carers may be needed.
• Daily care needs: medication, continence, eating and drinking, and any catheter or stoma care where relevant.
• Cognition and decision making: memory, understanding and decision-making ability.
• Risk and wellbeing: falls risk, general safety, skin condition and likely overnight needs.

The assessment also considers the person’s previous level of independence, their current abilities and the support they are likely to require the first days and weeks after discharge. This information helps determine the appropriate level and type of care for the person’s individual circumstances.

With the person’s consent, we can use relevant discharge information and care records to support care planning. This allows the assessment and care plan to take account of the information recorded by the hospital, alongside our own assessment of the person’s needs.

Where equipment has been recommended, a separate home assessment will usually be arranged while the person is still in hospital. This may be completed with the next of kin or another nominated person who can provide access to the property.

The assessment checks whether the home environment can safely accommodate the recommended equipment and support arrangements. This may include:

• whether there is suitable space for a hospital bed;
• whether equipment such as a hoist can be used safely in the proposed location;
• whether required items, such as a commode, have been delivered;
• whether access to and within the property is appropriate for the person’s needs.

Where possible, these arrangements can be completed at the same time. For example, a home assessment may take place whilst the Service Manager is assessing the person at Ipswich hospital. This can allow practical arrangements and carer matching to begin before the discharge date is confirmed, which allows for care to start the same day as discharge.

Suffolk Home First Reablement and What Happens When It Ends

In Suffolk, reablement following a hopsital discharge is provided through the County Council’s Home First service. Reablement is provided free of charge for a limited period of up to six weeks.

The use of the term ‘Home First’ can cause some confusion because it refers both to a wider approach and to a specific service. Home First as an approach supports people to return home where this is safe and appropriate, which underpins the use of Pathway 1.

Home First as a service refers to the support provided to help eligible people regain or maintain independence following discharge.

This service is delivered by reablement support workers, with additional provider capacity used where required. The duration of support depends on the person’s progress and assessed needs. Some people may require support for only a short period, whilst others may receive reablement for up to the maximum six weeks.

If the person still needs support after reablement, longer-term care arrangements may be considered through the council’s adult social care process. Any ongoing support should be based on the person’s assessed needs, circumstances and preferences.

This may include:

• Council-arranged care: Adult social care may help arrange ongoing support where the person is eligible.
• Privately arranged care: Families may choose to arrange care directly, or ask for an existing preferred provider to be considered.
• Continuation with a chosen provider: If A Class Care is already involved, we can discuss whether an ongoing package can be put in place. A Class Care is an approved provider in Suffolk and is registered with the CQC.

Any charges for longer term care depend on the outcome of the relevant care and financial assessments. The council will consider the person’s financial circumstances when deciding whether they are eligible for funding. Generally, if you fall below £23,250, you will be entitled to some funding.

Care After Ipswich Hospital Discharge: How Quickly It Starts

How quickly care can start

Once a person is clinically ready to leave hospital, we generally aim to have care arrangements in place within 24 hours to three days. The exact timescale depends on the person’s assessed needs, their location, whether any required equipment is available, and the availability of appropriately matched carers.

What can affect the timescale

Some care packages can usually be arranged more quickly than others. For example, support with personal care, medication, and meals may be easier to put in place promptly.

More complex arrangements may take longer to organise and assess safely, particularly where they involve:

• double-handed care
• specialist equipment
• a higher level of risk
• more frequent visits
• waking night or overnight support

Planning before discharge

The amount of notice before discharge can vary. In some cases, we may be contacted several days before the person is clinically ready to leave hospital, which allows planning to begin in advance. In other cases, care may be the final outstanding arrangement before discharge can take place.

Where contact is made before the discharge date, the ward assessment, home assessment, and initial carer matching can begin while the person is still in hospital. Completing these steps in advance may help care start promptly once the person is ready to return home.

Types of support available

Support following discharge from Ipswich Hospital can include:

• daytime visits
• multiple visits each day
• support after a period of reablement
• waking night or overnight care
• short-term intensive support
• live-in care
• longer-term care

Urgent arrangements

Where a person’s circumstances require an urgent response, the assessment and care planning process can be prioritised according to their needs and the availability of a suitable care package.

Frequently Asked Questions

What does medically fit for discharge mean?

It generally means that the person’s acute hospital treatment is complete, and they no longer require an acute hospital bed. Their ability to manage at home and the support they may require after discharge are considered separately as part of the discharge planning process.

What is the Transfer of Care Hub?

The transfer of care hub coordinates discharge agreements and the health, social care and community support a person may require after leaving hospital. It works with hospital teams, patients, families and relevant health and social care providers. A case manager may be allocated where coordination across services is required.

Can a private care provider assess someone whilst they are still in hospital?

Yes, subject to the person’s consent and the appropriate arrangements with the hospital. Our Service Managers can complete care assessments whilst a person is at Ipswich Hospital and liaise with the ward and discharge professionals when planning care at home.

Do we have to accept the discharge date if care is not in place?

Discharge arrangements should take account of the person’s assessed needs and the support required for a safe return home. If care, equipment, medication or another element of the discharge plan is outstanding, families should raise this with the ward and ask what arrangements remain to be completed. The transfer of care hub may also be involved where coordination of discharge support is required.

Who do we contact with a concern about the discharge itself?

To raise a concern, contact Ipswich hospital PALS on 0800 328 7624, open weekdays 8-4.00pm.

Arranging Care with A Class Connect from Discharge

We provide home care and live-in care for people returning from Ipswich hospital across Ipswich and the wider Suffolk area. Where possible, we encourage families to contact us when the person is still in hospital so that an assessment and initial care planning can begin before the proposed discharge date. However, we will do our best to accommodate every request.

For families who require care before a funded package has been agreed, privately funded emergency care at home may be available from the first day, subject to an assessment of the person’s needs and carer availability.

Please don’t hesitate to get in contact with our team by calling 01223864066 or email referrals@aclasscare.co.uk to discuss the person’s circumstances and he support that may be required following discharge.