Transfer of care
Information for patients and families
This leaflet guides you and those important to you on the process of transferring your care from the inpatient unit. The nursing , medical and therapies teams will work with you and those important to you to coordinate your transfer to your ongoing place of care.
Why is my place of care being discussed?
Royal Trinity Hospice is not a long stay facility and the length of stay will vary depending on your individual needs. You might only be with us for a few days, or if your needs are more complex or changing , you might be with us a while longer
Although we do not provide ongoing inpatient care, if your condition stabilises or if you improve enough so that care can be provided elsewhere, we will work with you and those important to you to identify the best place for that care This may be your own home or it may be in an environment that provides 24 hour nursing care
Please don’t worry if we start talking about your discharge within a few days of your admission, this is a normal part of our planning. Some discharge arrangements can take time to put in place, therefore it is best to start the process early so that equipment and any other services can be arranged in good time if you move on from the hospice
What happens when it is time for me to leave?
We know leaving our inpatient care can be daunting , but before you leave, we will make sure that everything is in place and that you have the correct support to manage your care and needs.
If you are eligible, we will make sure that relevant funding is in place to meet your needs. We will ask your permission to carry out an assessment of your health and social care needs and whether we can share this information with relevant professionals. Funding may be available from Social Services or through Continuing Health Care (CHC) to make sure that you continue to be supported either at home or in an alternative place of care, such as a nursing home
Once funding is arranged you will be given possible options for your ongoing care You and those important to you will have time to review these and make a decision about how you would like to proceed.
What if I want to go home?
If you wish to go home, we will work with you and those close to you to assess your needs and find ways we can support you once you leave the inpatient unit This may mean carers visiting you at home to assist you with your daily activities such as washing and dressing. Our occupational therapist and physiotherapist will assess your physical abilities and give advice on what equipment might make your home environment safe for discharge. They may want to arrange a home visit to work out what is needed and make arrangements for equipment to be delivered to your home e g. hospital bed, commode etc.
What if I want to go to a nursing home?
If you decide to go to a nursing home, you may be eligible for NHS Continuing Health Care funding. The Integrated Care Board (ICB) in the area you live will provide you and those important to you with a list of preferred provider care homes agreed by the NHS
Before you are discharged, a nursing home to suit your needs will be sourced by the ICB and the nursing home will then call our nursing team to do an assessment If the nursing home feels they can meet your needs and there is availability, your next of kin will be contacted to offer a visit
Once everyone is happy, a confirmation of placement is agreed and then a discharge date set.
What happens if I can’t choose somewhere I like?
The team can support you in communicating with the ICB to express your preferences.
The ICB will take these preferences into account, however decisions may come down to bed availability in the community
When I am transferred, will I still have contact from Royal Trinity Hospice?
If you are known to our Community Palliative Care team, they will keep in contact and visit you, either in your home or nursing home when needed. If you are out of our catchment area, we will refer you to your local Community Palliative Care team who will continue to keep in contact and visit You may also be able to come to the hospice for Living Well outpatient services such as complementary therapy, art therapy and
physiotherapy This may be decided before you are transferred home or may be suggested by your Community Nurse Specialist.
Once you are home, we will transfer your medical care back to your GP who will be responsible for your day-to-day care, along with other community healthcare professionals such as District Nurses. They will keep us updated of any changes to your condition.
What happens to my medication when I leave Royal Trinity Hospice?
While you have been an inpatient your medication may have changed. Our medical team will have discussed your new medication with you and will have carefully monitored whether it is improving your symptoms. This allows us to be confident that when you leave the inpatient unit, you are taking the most effective medication in the most appropriate doses.
Just before you leave we will order two weeks’ supply of all your medication. If you are taking a lot of tablets, we may supply these in blister packs to make it easier for you to manage your own medication. We will send the list of your medications to your GP and District Nurse
If there is anything you or those important to you are worried or concerned about once you are home, or in a nursing home, you can still call us for advice, anytime day or night, on 020 7787 1000.