Stay at home or go into a home? That is not (necessarily) the question.

The effectiveness of plans made to support an elderly person following a spell in hospital can make all the difference between continuing their previous life and a fundamental life change. It is bad practice to place a person in permanent resdiential care straight from hospital without exploring and exhausting the alternatives first.

Where the admission itself is planned, a social services assessment of the care required on discharge can be requested even in advance of the admission.

NHS and social services rehabilitation- who has responsibility?

An acute health crisis such as a stroke or a broken hip is likely to mean that the patient will need care after they leave hospital. The patient may be transferred to an NHS inpatient rehabilitation unit once the acute treatment is completed.

In some cases, the NHS retains a legal responsibility to provide rehabilitation care when the person is discharged from inpatient care. Currently the hospital that provided the acute care is responsible for the first 30 days of home care after discharge from hospital for the following conditions:

• Cardiac rehabilitation
• Pulmonary rehabilitation
• Hip replacement
• Knee replacement

The aim of placing this responsibility on to the hospital is to avoid the situation where there is any incentive to discharge a patient home before they are properly ready which is likely to result in their readmission.

When considering discharge planning, the NHS must decide whether it has a legal responsibility to provide full continuing care. It may screen a patient by completing a simple "checklist" assessment. If a full assessment is warranted it will convene a team of all the relevant professionals called a multi-disciplinary team (MDT).

This decision has important financial consequences.  If the NHS remains responsible for continuing care, that care will be free. If not, then unless they are on a very low income, the patient will have to pay for this themselves either entirely or by making a contribution to social services funded support. You can ask to be invited to this MDT meeting. It is important that you are properly prepared by understanding how this decision is taken so that you can contribute effectively.

If the patient is not eligible for full NHS continuing care, the NHS may still contribute to their care not only through GP and district nursing services but also through joint funding of the care package.

If the hospital decides that they are not responsible for continuing care and they can identify a date for discharge, it should establish with the patient and consult with any  carer whether the patient wants to make their own arrangements for care.

If the patient asks for social services support, the hospital should issue an "assessment notice" to the local authority. A notice can be issued even if the patient and or the carer has objected to it. This may happen if there are issues about the capacity of the patient to make that decision or if the carer's proposals appear unsafe.

The social services department should then carry out an assessment before the discharge date set by the hospital. Subject to a 2 day minimum notice period, the local authority may incur a financial penalty if it misses that deadline.

Social services rehabilitation care – Is it free?

Free intermediate care funded by the local authority may be available for up to 6 weeks. This is in addition to any rehabilitation care that has been provided by the NHS.

Government Guidance (2009 guidance) has described intermediate care as:-

"a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and maximise independent living." Extract: Intermediate Care – Halfway Home – Updated Guidance for the NHS and Local Authorities (2009)

A local authority programme can last for longer than 6 weeks, but following this the individual should be means tested.

The 2009 guidance notes that those at risk of being placed in residential care inappropriately should be a priority for preventative support. It states that:

"All older people at risk of entering care homes, either residential or nursing, should be given the opportunity to benefit from rehabilitation and recuperation and for their needs to be assessed in a setting other than an acute hospital ward.

They should not be transferred directly to long-term residential care from an acute hospital ward unless there are exceptional circumstances. Such circumstances might include:

● those who have already completed a period of specialist rehabilitation, such as in a stroke unit

● those judged to have had sufficient previous attempts at being supported at home (with or without intermediate care support)

● those for whom a period in residential intermediate care followed by another move is judged likely to be distressing."