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s n o i t p O

October 2012 | 1st Edition

A Guide to your Discharge from Hospital

How am I referred to the social work team?

The assessment process

Home Enablement Services

24 hour Care homes




Contents A Guide to your Discharge from Hospital October 2012 Contents Our hospital team


How am I referred to the social work team?


The assessment process


Continuing NHS Care


Getting the most out of your assessment


More about the assessment


Assessments and carers


Intermediate care


Home Enablement Services


24 hour Care homes


What happens next?


Discharge from Hospital


Problems or queries


Other sources of help for when you have left hospital


Other sources of help after you leave hospital


Rehabilitation into the community Contact Details


Alzheimer’s Society Services in Rotherham


Age UK


Whilst every care has been taken to make sure the information in this publication is up to date it is not intended to be a complete and authoritative statement of the Law on the issues covered. The publishers and the promoters cannot accept responsibility for any loss arising from the use of information contained in this publication. Designed and published by Octagon Design & Marketing Ltd, 01909 478822

Whilst we have taken every care in compiling this booklet, the publishers and promoters cannot accept responsibility for any inaccuracies. The inclusion of any advertisement in no way endorses the services or products sold.


Introduction For most patients, being discharged from hospital to their home is straightforward. Most are unlikely to need the support of Social Services, though some may need some information or advice about social care. However some people have new or ongoing health and social care needs which require a detailed assessment. Staff from Health and Social Services

will usually work together to plan and deliver services to support such people after discharge. This guide explains some of these processes, and explains the role of Adult Social Services in the hospital discharge process.

Our hospital team Adult Social Services in Rotherham have a social work team based in Rotherham General Hospital.

How am I referred to the social work team? Planning for discharge normally begins at the point, or even before, you are admitted to hospital. The discharge process will be coordinated by a member of the nursing team on the ward. Following an initial assessment by nursing and medical staff, you will be referred, with your consent, to the hospital social work team if you appear to have social care needs that require assessment prior to your discharge. 4

This is done by the ward sending a section 2 Notification. (Delayed Discharge Act 2003). You can also give your consent to your carer who can ask for you to be referred to the social work team. If you have any queries or want any general advice you can contact the Adult Services Health and Social Care Information Facilitator on 01709 424650

The assessment process A member of the social work team allocated to your particular ward will contact you. The assessment is not a test, but a way of working out what your needs are and which ones might be putting you at risk. The assessment process will start with discussions with the ward staff, with you and your family/ carers. This process of information gathering and clarification of the situation will enable the social worker/social services officer to work alongside you to: • identify your needs • establish your eligibility for services (our eligibility criteria is set so we are only able to support people who meet Fair Access to Care level at ‘critical’ or ‘substantial’ level. (For more information please visit )

In Neighbourhood and Adult Services, we aim to do what we can to help people to live independently and safely. We work within resources available to us, and therefore ensure that we prioritise the people who are in greatest need of help. This guide tells you more about assessments and eligibility criteria. It also tells you about what will happen after you have an assessment. This may be relevant to you if you are an older person (65+), have a physical or sensory disability, have mental health problems, or have a learning disability.

• give you information about services that could immediately support you to be discharged from hospital or support you in the longer term. Depending on how complex your care needs are, other specialist assessments may also be required. The referral process and time scales for assessments are outlined in the Delayed Discharge Act 2003. The length of time required to complete the process can vary depending on how complex your needs are. 5

Continuing NHS Care If you have complex, ongoing health care needs the team involved in your care, must first consider whether you meet the eligibility criteria for Continuing NHS Care. If you are entitled to NHS continuing healthcare the health authority staff will discuss with you how your needs and care will be managed. This can be provided in any setting e.g. your own home, a nursing home or in hospital. If you have met the criteria a comprehensive assessment of all your needs will have been completed by the multi disciplinary team (MDT). This is


the collective name for the different professionals involved in your care i.e. doctor social worker, nurse etc). If you are not eligible to receive NHS continuing health care but still have health needs, then the NHS may pay for part of the package for support, this is called a joint funded package. (For more information please visit Carers may also be entitled to support that would help them in their caring role. If you have an identified carer, this would also be an appropriate time for them to receive a carer's assessment from Social Services.

Getting the most out of your assessment You might want to prepare for your assessment by jotting down anything you want to talk through with us. What is difficult for you? What kind of help are you having at the moment? Are some days much easier than others? If so, why do you think this is?

We know that there are some things which can be difficult or stressful to talk about, but please don't be embarrassed. We will understand your feelings and respect them. If your first language is not English, or if you use sign language, we can arrange for an interpreter. Please let us know what you need.

More about the assessment Once the ward has asked for an assessment, one of our staff will come and visit you on the ward. You can have a friend or relative with you at the assessment, if you wish. The assessment is free and will involve discussions about; • What difficulties you are having at the moment; • What type of help you feel is needed; • How stressful and urgent you feel your situation is. We look at four main areas of life: 1) How much control you have over your own life, and how easy or difficult you find it to make decisions about the way you live

2) Your health and safety, including any risks to your mental health or wellbeing 3) Your daily routines, such as personal care and domestic chores, and how well you are able to manage them 4) How well you are able to involve yourself in family responsibilities, community life, and work or study. We may want to get information from other people, such as the Ward, Doctor, Therapists and family etc. We might share some of the information you give us with other people, but only when it is necessary to help to plan your care, on a 'need to know' basis with your consent. 7

More about the assessment On the assessment form we write down everything we discussed and agreed with you during the assessment, and also anything we might have disagreed about. You will get a copy of the

completed assessment form to keep. Following the assessment, we will give you information about support that may be available, and any charges involved.

Assessments and carers If you have a carer - a relative or friend who provides you with unpaid help - we may want to talk to them about what help they are able and willing to give. Carers may also be entitled to support which helps them in their caring role. If


you have an identified carer, this would also be an appropriate time for them to receive a carer's assessment from Adult Services. Please ask us for more information on this.

Intermediate care Intermediate Care is the name for support to help you build back your skills and enable you to live at home as independently as possible. In some cases hospital staff may recommend a period of rehabilitation in order

to maximise your independence. A member of the Therapy Team would assess you for this. An intermediate care service may be provided by community health and social care services to support you during this period.

Home Enablement Services You may be assessed as benefitting from Home Enablement Services for your return home. The Home Enablement Service provides re-enablement for adults aged 18 years and over within their own homes. The service is for people who require support at home so that they are able to achieve optimum levels of independence and therefore remain safely at home.

your own without any or little help. If you require continued support after this period you will be assessed under Fair Access to Care Services criteria and a financial assessment would be undertaken as there may be a charge for any ongoing services.

It will help you regain your confidence and your ability to do things for yourself after your spell of illness or your recent accident. The service is available for people for up to six weeks and can be extended to up to 8 weeks in exceptional circumstances. The service is free of charge for a period of up to six weeks. The Home Enablement Service is designed to encourage and support you over the weeks to enable you to gradually carry out your personal care needs and tasks around the home on 9

24 hour Care homes If it is felt that you can no longer manage at home even with support, the decision may be for you to move to a care home. You and your family will be involved in this decision. The assessment will identify your care needs. This will help you and your family to select a registered care home which will be able to meet your needs. There are 3 categories of care homes. • Residential care – provides accommodation meals care and support throughout the day and night. • Nursing care – offers the same as residential care with the addition of 24 hour care by a qualified nurse.


• Dementia care or EMI (Elderly Mentally Ill) care – which provide specialist extra care for people often due to dementia or other mental health diagnosis. You and your family have the right to choose the care home you will move to. During the care planning process you should be supported to identify a suitable care home which is registered to meet your needs and has a vacancy. Your social worker/social services officer can help you with this process. However if the home of your choice has no vacancy, you may have to accept a place in an alternative care home until a place in your home of choice is available.

What happens next? Once you are declared medically fit for discharge by the medical team and all the appropriate assessments have been completed, Adult Services will be

formally notified by the ward by sending a Section 5 Notification (Delayed Discharge Act 2003) to the hospital social work team.

Discharge from Hospital Once all assessments are completed the social work staff will discuss with you what help may be available and decide with you how your care needs can best be met. Your discharge should take place in a timely fashion. We will endeavour to

give you a copy of your individual social care assessment and support plan before leaving hospital. If this is not possible we will give you a discharge letter giving you an overview of your planned care and your individual social care assessment will follow in the post.

Problems or queries If you have queries or are experiencing difficulties relating to your discharge you can either contact your social worker/ social services officer or speak to the nurse caring for you on the ward. If a social worker has not been allocated to you, you can contact the hospital social work team to speak to a Health and Social Care Information Facilitator who will assist to resolve any problems or issues which are the responsibility of Social Services.

The hospital social work team have a member of staff whose role involves supporting the black minority ethnic communities with their social care needs during the hospital discharge process. Contact number 01709 424650

They can also give further information and contact details you may find helpful. Tel 01709 304650 11

Other sources of help for when you have left hospital Rothercare Direct 01709 822330 – search for Help at home If you think that you may need help from the Council you can ask for advice or a care assessment by contacting Rothercare Direct. To make things easier for you we have set up a first point of contact for all our services called Rothercare Direct. You can speak to an Officer who will listen to your enquiry, advise and assist you, and make sure you receive an assessment if required. We can help you with: • Social care assessments • Carer's assessments • Safeguarding vulnerable adults • Disabled person parking permits (Blue Badge) • Adaptations within your home • Community alarm scheme • Occupational therapy assessments • Any other aspect of your social care Age UK – Rotherham 01709 835214 or 01709 786958 Age UK are an independent charity whose objectives are to make the lives of older people in Rotherham as fulfilling and rewarding as possible. Age UK can help you with a variety of day opportunities that are fun and 12

offer companionship when used as part of a care plan can help older people remain healthy and well. Access to community information about housing, benefits, products and services (home insurance, motor insurance etc) Carers Centre – 01709 254809 Caring for someone is not always easy which is why the Council and its partners have all come together at 'Carers Corner' to provide you with all the support you need under one roof. At Carers Corner you can get face to face advice - such as how to access benefits or legal advice, along with how to access the Carers Emergency Scheme and Carers Assessments. Advice and guidance is also available through the Ask My Community Website. Community Occupational Therapist Service – 01709 822330 The Community Occupational Therapy Team helps anyone who is elderly or disabled and is having problems with activities of daily living. You can refer yourself for help, or someone else can contact us on your behalf. All contacts to the Community Occupational Therapy Service are taken by Rothercare Direct. They may be able to respond to your problem at the point of contact or

they may pass your request to another agency, such as the Home Improvement Agency. If they are unable to do this, your request will be passed to the Community Occupational Therapy Team. Physiotherapist Service - Badsley Moor Lane – 01709 422323 We offer a range of treatments including manual therapy, electrotherapy, acupuncture, hydrotherapy, education and self-help programmes, active rehabilitation and chronic pain management. department.aspx?id=198

Rehabilitation into the community Contact Details: Rotherham Intermediate Care Centre (RICC) – 01709 514003 The Rotherham Intermediate Care Centre, located on Badsley Moor Lane, is a joint partnership between Rotherham Council and Rotherham Foundation Trust. The centre is set to provide new rehabilitation facilities within a day setting for the people of Rotherham The new centre will work as an intermediate care hub, bringing together therapists, specialist mental health workers and support workers who are

providing services to promote and maximise independence following a patient's recent episode in hospital, change in functional abilities or a worsening of their long-term condition. The new service will provide activities which are tailor-made to a patient's own interests and abilities. You can also view this booklet on the RMBC internet site www.rotherham. where updates may be added. This booklet was written by Rachael Crehan


Alzheimer’s Society Services in Rotherham If you think you may have a form of dementia, or are caring for a person who has dementia, there are many ways that Alzheimer’s Society in Rotherham can help. Someone to talk to You can phone at any time during our opening hours to talk in confidence with a member of our Dementia Support Team. Our team are here to listen when you just feel the need to talk, or to offer advice on specific issues. Support from Dementia Support Workers Our Dementia Support Workers can offer advice on accessing professional help. We are in touch with a wide range of services and other advice centres throughout Rotherham, so we can put you in touch with specialists who can help you if your concerns are outside of our expertise. We can also refer you, or the person you care for, to services provided for people with dementia in Rotherham, particularly if you are having trouble accessing these yourself. Home Visits We can also arrange for a Dementia Support Worker to visit you at home and provide information, advice and support. 14

Information Worker Our Information Worker is available to attend community groups, Lunch Clubs, Day Centres or other social events to talk to you about dementia and the services available through Alzheimer's Society. We also have a wide range of information and advice sheets which include specific information on different types of dementia, care issues and understanding the needs of the person with dementia. Singing for the Brain An innovative project providing structured musical stimulation for people with dementia and their carers. Singing is an enjoyable activity and provides a way for people with dementia to express themselves and socialise with others in a fun, supportive group. Groups run once a month. Dementia Café Anyone who has dementia or is caring for a person with dementia is welcome to attend the monthly Cafés and Lunch Clubs. Each Café and Lunch Club is staffed by Alzheimer’s Society workers and volunteers. Staff from partnership agencies including Social Workers, Community Psychiatric Nurses and Occupational Therapists are invited to

attend the groups. Please contact us for more information including dates and times. Carer’s Education Group Our Carer’s Education Group is a series of four workshops for carers of people with dementia. This programme is for anyone caring for a person with a diagnosis of dementia and aims to offer structured information to inform and support the caring role. Carers do not necessarily have to live with the person with dementia.

Membership All members of Alzheimer’s Society receive a monthly national magazine. The more members we have, the greater our lobbying power. Membership is free to carers and people with dementia.

Fundraising As a charity we rely heavily on donations to maintain our levels of service. If you would like to help and are able to make a donation of any amount please contact us at the Mexborough office. All donations will be greatfully received. What should I do now? For information, advice and support, please call us on 01709 580543. We are open from 9am to 5pm, Monday to Friday Alternatively you could visit us at: Alzheimer’s Society Doncaster and Rotherham Room F9, Mexborough Business Centre College Road, Mexborough S64 9JP 15

Age UK Rotherham Services Age UK Rotherham became the new name for Age Concern Rotherham in April 2011. We have been working with and campaining for older people since 1974. We are an independent charity, whose objectives are to help older people who live in Rotherham to maintain their independence, health and well being by providing services that meet individual needs. We recognise that you want a choice in how you are supported, to continue to remain independent in your own home. The following services are designed to offer you support when and where needed to keep your independence. Services to support independence We currently offer a range of health and wellbeing services, which include: St Anns Social Centre The centre aims to help you feel less socially isolated and to keep you active by providing you with an opportunity to meet friends and participate in various activities like: Crafts, gentle exercise, guest speakers, outings, toe nail cutting, massage There is a choice of lunchtime menu that will be cooked fresh on site. Independence At Home Our services offer a comprehensive range of support so that you can be happier in your own home, stay safe and remain independent. We have over 20 years experience of providing a trusted service to older people in Rotherham. The team are trained, caring and fully vetted for your safety. Our services include: 16

Domestic help – Cleaning, laundry, shopping, prescription collecting etc Handypersons – Minor household repairs, home safety and security, plumbing repairs Gardening – All year round garden maintenance, fence/gate repairs and general garden tidying Independent Living Support – Support packages can include : Assisted bathing, meal preparation, hair washing The above services are chargeable Advice & Information Services – This is a free service We can offer drop in sessions or home visits to provide you with advice on a range of issues including: Benefits, housing, community care and general health and welfare. We can also provide: • Help to complete forms and make applications • Advocacy support to help you with complex issues Trading – This is a free service A wide range of products and services have been designed for people in later life these include: Home insurance, car insurance, motor breakdown, travel insurance, gas and electricity, funeral plan, will writing. Age UK Rotherham is an appointed representative of Age UK Enterprises Ltd which is authorised and regulated by the Financial Services Aurthority for insurance mediation. For any further information on these services please contact 01709 835214


Helping and supporting you at difficult times Hospital Aftercare Service – This is a free service

to get home quicker.

Age UK Rotherham has been running a support service for older people being discharged from hospital since 1996. The team will support you on discharge from hopsital by offering you:

If you feel you are lonely and isolated we can provide you with a fully trained and police checked volunteer to visit you at home. The service will provide companionship, or give you confidence to join back in local activities.

Non clinical assessment – This is an holistic assessment of your own individual needs supporting you to regain your independence and confidence following your hospital stay Provide a short term package – We have trained enablers that can visit you for up to 30 days to assist you to remain independent and offer reassurance and support with your daily living activites including: assistance with meal preparation, shopping, cleaning, mobility issues etc

Befriending Services

We can also provide you with a link line telephone support call, which provides a reassuring call to you each morning or when requested. This can be on a permanent or temporary basis if your carer is away. For any further information on these service please contact 01709 786958

Signposting – We will give you information or refer to other services that may help and support you now that you are back home, and ensure you are getting the correct benefits you are entitled to Transport – We can take you home from hospital providing you are mobile and able to get into a car and need help to settle back home after your hospital stay which would mean you would get home sooner and not be waiting for other forms of transport Hospital medication – We can return to the hospital to collect your medication from the pharmacy, this will enable you 17

Questions I would like answering:

Whilst every care has been taken to make sure the information in this publication is up to date it is not intended to be a complete and authoritative statement of the Law on the issues covered. The publishers and the promoters cannot accept responsibility for any loss arising from the use of information contained in this publication. Designed and published by Octagon Design and Marketing Ltd, 01909 478822


Whilst we have taken every care in compiling this booklet, the publishers and promoters cannot accept responsibility for any inaccuracies. The inclusion of any advertisement in no way endorses the services or products sold.


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Designed & Compiled by Octagon Design and Marketing Ltd., Britannic Chambers, 8a Carlton Road, Worksop, Notts. S80 1PH Tel: 01909 478822

A Guide to your Discharge from Hospital  

A Guide to your Discharge from Hospital, Rotherham Council, October 2012

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