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Coming out of hospital

If you're unlikely to benefit from short-term support and need residential or nursing care

It may be that you have long-term identified when you're ready to be discharged. This only happens in exceptional circumstances.

Hospital staff will talk to you, your family and/or carers about your long-term needs. They'll also let us know that you need longer-term support.

We'll arrange for a social worker, care manager or (in some cases) an inreach nurse to arrange your support when you're discharged to a care home, or long-term support in your own home if appropriate and you're eligible.

You may need a level of long-term support at the point of leaving hospital if:

  • you have complex or significant health and/or social needs, and these can no longer be met in your own home
  • you're unable to return to your previous care home because there's been a significant change to your health and/or social needs
  • you have life-changing care needs
  • you need complex end of life care
  • continuing Health Care Fast Track
  • under Section 117 Aftercare
  • you have complex mental health needs
  • you have complex housing or homeless needs

Depending on your assessed needs, your case worker will support you and your family by completing relevant health or social care assessments so you can leave hospital with the right support in place.

If your needs assessment shows you have eligible social care needs, you can have a financial assessment to work out how much you'll need to pay towards care in your own home. You could choose to have a direct payment. This is where you can arrange your own support with who you want to use, instead of of us arranging services for you.

If your needs assessment shows you have eligible needs for residential or nursing care, you can have a financial assessment to work out how much you'll need to pay towards your care home.

If you have complex, intensive and unpredictable health needs, you may be eligible for a NHS Continuing Health Care funding assessment.

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