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CareMapIreland

Hospital discharge

Hospital discharge team and medical social worker

The people in the hospital whose job it is to plan safe discharge and arrange supports before the person goes home.

Public / statutory scheme

Last reviewed: not yet reviewedNeeds review

Discharge is the single best moment to get supports organised, because the hospital team can make referrals directly and the person's needs have just been assessed.

Be specific and early. "She cannot manage the stairs and there is no downstairs toilet" changes a discharge plan; "we are worried" often does not.

If you believe the proposed plan is not safe, ask for a discharge planning meeting and ask for the plan in writing.

Who it's generally for

Anyone in hospital whose situation at home has changed, and their family.

What it provides

  • Discharge planning, including referrals for home support or short-stay rehabilitation
  • Input from hospital professionals who may be involved, such as medical social work, occupational therapy or physiotherapy
  • Information about community services relevant to the person's situation

The eligibility and assessment caveat

Discharge planning is decided by the hospital team on clinical grounds. Families can raise concerns and ask for a discharge planning meeting, but cannot direct clinical decisions.

What to do next

  1. Ask who is managing the discharge plan, and ask them for a HSE Home Support application form as early as possible
  2. Ask for a discharge planning meeting if you are worried the plan will not work at home
  3. Say clearly and early what will and will not be manageable at home
  4. Ask what has been referred, to whom, and what will already be in place on day one at home

Documents and information worth preparing

  • A written list of what the person could manage before this admission
  • A description of the home: stairs, bathroom, heating, whether anyone else lives there
  • The names and availability of family who can help, honestly stated
  • A list of current medications and any equipment already at home

Questions worth asking

  • What supports have been referred or approved before discharge, and when do they start?
  • Will there be a period of rehabilitation or a short stay first?
  • What equipment will be delivered, and who delivers it?
  • Who do we contact in the first week at home if it is not working?
  • Has the Public Health Nurse been notified?

Official sources

We summarise. The organisations below are the authority on current rules, rates and thresholds.