Unsafe discharge from hospital

[PaintYourDreams]

I hope someone can help me with this one please. My MIL was taken into hospital a few weeks ago and it was a nightmare to get her there. She was very unwell but also extremely hostile to any medical intervention and it was very upsetting all round but once she was there and being treated she's accepted it and doing better but still quite a lot wrong with her that will need ongoing treatment.

The problem is that we've been told by a discharge person (not a nurse, I don't think) that at some point they will discharge her by either us collecting her or them taking her home where they will do a two hour 'assessment' to see if she can cope at home. So the assessment will be done once she has already been taken home. MIL will say yes she can manage fine but she was in a terrible mess and not coping at all when she went into hospital and we think that daily carers and a stairlift are the minimum needed. None of this will be in place if they just bring her back and then decide she doesn't need help. Or if they decide that she can't manage, then she's had all the trauma of being taken home and then taken back to hospital.

So I guess my question is whether this is the normal way that an assessment is done or does this mean that they've effectively decided she is discharged back to her house as it is even though we don't think this is safe.

Yes, this sounds standard (it is in my county). Contact your local Age UK as soon as possible for advice and support. They may have services specifically for people coming out of hospital.

Yes this is a new thing basically anOT home visit but they don't have to go back. What do you feel she needs daily carers to actually do? If you feel she needs personal care then you can ring the discharge coordinator back and tell them so. She may need an occupational therapist assessment on the ward which would establish her care needs. But if she is self caring on the ward this would not be necessary. If she has over £23000 in savings she would need to be paying towards her care in any case so if she agrees you could just contact a private care agency. Stairlifts are done through occupational therapy at the council but usually take minimum 6 months. You can refer her to get the ball rolling. A sime straight stairlift costs around £3000 try ascendit or higher elevation if she wants to pay for it herself. Avoid acorn. Discharge coordinator s are usually experience d nurses.

Please make sure the hospital are crystal clear on your position. Your mil may well have said that x and y will be doing this and that/ staying over etc etc. what support do yo7 want to give? Be v careful.

I think the question is does she have capacity? If so, what has she said to the hospital? They can not force her to go to eg a nursing home for an assessment if she does not want to. And they are not obliged to guarantee a “safe” discharge if she insists on going home. It is different if she lacks capacity.

On the positive side she should qualify for up to six weeks free LA care after a hospital discharge. This could be up to four visits a day to help with basic medical needs, personal care, shopping, preparing and eating food etc. They can also organise a key safe, grab rails, fall alarm and help with making shower etc more accessible (at a cost) . IME this can all be done within 48 hours. Thereafter she will have to pay for carers herself if she has assets of over c£30,000 but LA will pay if she has no money and they assess she has ongoing needs. But again she can refuse this if she has capacity even if this is the wrong decision.

It is difficult as a family member but I would make it clear that there will be no family support. Obviously you can still offer it going forward, but do not let the LA shunt their responsibilities in your direction.

The taking her home for an assessment sounds like discharge to assess, the bed is held and if she isn’t safe at home they will take her back to hospital.

The hospital will also help organise carers if needed

We don't live near enough to go over every day so would be going over each weekend. She has no-one else to help her daily but she will say neighbours/us can sort everything out. The reality is she had got to the point of being unable to prepare meals or clear up, couldn't manage any laundry, continence issues, mobility issues for getting up stairs and to toilet etc. She was in a mess, quite literally, which we have entirely cleaned up now - perhaps we should have taken photos.

She mostly has capacity I would say.

Do you think we just have to accept that there will be a period of a few days or more when the help just isn't in place but will be soon?

She doesn't have much in way of savings but enough for stairlift and to pay for cleaner out of income. We're not really bothered about what we do or don't have to pay for, just worried that it seems like she'll be sent home with nothing in place.

If she has capacity then she can go home with or without care, thats her choice. You need to make it clear to her, the discharge co ordinator, the ward manager and social services what you feel she cannot do and that she is unsafe at home on her own and that there is no family or neighbour support. Do you have power of attorney. Do not offer to take her home, let the therapists and ward organise it. She will have had some assessments in hospital like walking, toilet, washing and dressing but they need to see how she is at home. There is always the danger that if she has an assessment at home and fails then she refuses to go back to hospital. They may suggest she lives downstairs and has carers and equipment in, stairlifts are expensive and not always the safest option. She will need a capacity assessment while she is in hospital.

There should be a social worker involved in her discharge at the hospital.
Try to contact them to discuss the plan for discharge.

Yes we have POA. It is highly likely that once home she will refuse to go back even if they decide it's unsafe for her at home. Which is why I'm not at all keen on the plan to bring her home and only then assess. I assumed that the assessment would be done before she came home so that everything would be in place, but new to all this.

Thank you for all the helpful response. I'm very grateful x

Do you think we just have to accept that there will be a period of a few days or more when the help just isn't in place but will be soon?

Don't assume anything will be in place soon (or at all). If a care package was being organised, the hospital would have informed you and they would be keeping her in until it was available.

Also, leaving the hospital to arrange her transport home isn't necessarily a good idea as it can be a bad (cruel) experience for patients. If you can take her home and settle her in, that would be better for her.

There is a massive crisis in social care and what someone is entitled to is not usually what they get.

As soon as she is home, you need to call Social Services, tell them she can't get a meal or look after herself.

The first thing is to have a capacity assessment, that gives you more of an idea. At some point the therapists would have either gone to her home to do an environmental check with or without her unless she self discharges. They need to see what she can do.

Whatever her level of savings she is entitled, if it is needed, to ‘enablement care’ on discharge from hospital.

See if you can talk to the Discharge Coordinator. Do not make any suggestion that you or neighbours can help, and be emphatic that anything your MIL says about this is not to be taken seriously.

If she needs care, you should in any case apply for Attendance Allowance, which is not means tested, and is paid to the recipient to spend how they like: cleaner, help with personal care, etc.

Usually they do not discharge a patient until the required Enablement Care is in place. Sometimes the NHS run out of carers and have to call on Adult Services. But that is for them to sort out, not you.

From experience I would try to keep her in hospital until the care package is in place and ready to start from the moment she arrives home.

We had a terrible experience with a relative where there was several days after going home before the care package stated. She couldn't get out of bed, couldn't wash, couldn't use the toilet etc, and we are not trained in lifting and helping elderly people about it really was a struggle and not very dignified for her.

Be very careful here. I agree, make it very clear there will be no family help. Ignore any guilt tripping. Don't mention going round every weekend, how sustainable (or fair to you) is that anyway? Think long term. As an ex district nurse I saw this scenario play out many a time, usually compounded by patients refusing to pay for care and subsequently in and out of A&E like a revolving door.
Unfortunately, it's often only letting things fail and a crisis develop which forces change permanently.

Ask to speak to the occupational therapist covering the ward and I'm sure they will be able to reassure you. This is normal practice over the last few years and is called discharge to assess. She will have been assessed on the ward to establish whether she is suitable for the scheme and carers, if needed, are part of the scheme along with further therapy input at home. If she has stairs then she will have practised them in the hospital first. You will not get a stair lift for discharge. If your MIL is unable to do the stairs they will liaise with family to see if downstairs living can be arranged, ie bed brought downstairs and commode supplied by the OT if no toilet downstairs or she will go to a discharge to assess bed in the community (in our Trust this is an 80 bedded care home) until she improves enough to go home. This is all funded for a few weeks. Do not worry, the occupational therapists are experienced in older people saying they can manage but will do their own observations as to whether the patient is able to get on and off bed, toilet themselves and stairs if applicable.

Thank you so much - really helpful information here.

Has your GP been involved at all OP? This happened to my Dad. He had short term memory loss and advanced bowel cancer. He was 90 and had lost my Mum three months earlier.

He was discharged home with the expectation that my Dsis would look after him even though she works and has her own family to look after. She was totally distraught and called the GP who had known him for years. She came round and said he was not fit to be left on his own and called an ambulance immediately.

His case was a bit different from your Mum because eventually he was moved to a hospice but I think you have to be very forceful because the hospital just want to discharge them. The state of elderly care in this country is dreadful, although having said this, the staff in the hospice were excellent and very caring (as were the staff in the hospital geriatric unit).

Does she have dementia? I would ask for a capacity assessment prior to her being discharged into the community. That can delay things a bit to allow you to work out next steps. Provide written evidence of unsafe choices and her inability to self care.

I would also say be wary of hospital staff trying to get you to agree to provide care. You need to be absolutely clear that the patient lives alone and will not have anyone to call upon.

I cannot emphasise strongly enough that you do NOT say you can visit at weekends.
Tell them you are not in a position to provide ANY support whatsoever. This might seem obstructive and uncaring, but if you say you can make a cup of tea for her ,they will expect 3 course dinners 3 times a day!!!
They have duty of care, and should not be sendjng her home without an appropriate care plan in place.
Stay adamant in this.

I agree with those saying that you need to make it very clear you can't provide care. My late DF was so determined to go home, he told the hospital social worker that I went in every day to assist him. I live 150 miles away, needed to go round the M25 to get to him, while doing school bus drop offs and pickups and holding down a full time job. She believed him, and made arrangements and was a bit surprised when she rang to tell me about her plans...

My experience is nearly a year old but the services were nearly all in place on the day of discharge. I wouldn't have believed it if I hadn't seen it. The key safe appeared before mum got home, the carers were in within two hours of her getting home, the district nurse was scheduled for the next day. My phone was ringing non stop all day. The one thing not there on the day was the fall alarm, that took about three days.

The assessment of her home situation was a phone discussion between the OT and me, by then mum wasn't up to answering questions. Before covid they would have come out to assess but at that time it wasn't happening. There was a six week free package of care, after which she would have picked up the cost. The agency had an online recording system and once mum had given permission I could log on and see that someone had been and what they'd done. It was a far better system for family than the paper file that MIL had.

@FelicityBeedle

The taking her home for an assessment sounds like discharge to assess, the bed is held and if she isn’t safe at home they will take her back to hospital.

The hospital will also help organise carers if needed

They absolutely won't hold her bed for her, they'll fill it as soon as she's discharged, such is the pressure on hospital beds.

No - this is not right. I used to be a hospital social worker and the assessment comes BEFORE the discharge. I sometimes used to organise a home visit with the OT to see how things went, but the patient went back to the hospital until everything was in place.

Bed-blocking I know; but there is absolutely no point in sending someone home if they are going to fall/burn themselves/become malnourished - they just finish up back in hospital.

As I understand it, hospitals are not allowed to send people home without proper care in place - I am assuming the same is still the situation.

Unfortunately getting the care you need often involves a battle. I speak from the bitter experience of trying to get proper care for my OH in a similar situation.

I am sure that this apparent new way of doing it is a wonderful scheme on paper, but I would not be at all happy with it - like you OP it is totally arse over tit.

Beware of being the assumed carer. Make it clear what you can and cannot do. As the wife it was assumed that I would do everything - but I had my own health problems and had to be very firm about what I could manage.

He qualified for continuing health care funding (where someone's needs are so great that they are treated as though they are in hospital and the NHS funds it) but this was refused twice. I appealed and it was granted - he had died by then.

It is not a good system at all, and the priority to get people out overrides their safety and well-being. It is a huge problem that needs radical reform to find a solution - but no government will bite the bullet on this.

Please make sure you get all the advice you can. Age UK are good.

You've had excellent advice on here. I'm a social worker

I used to do hospital discharges pre covid when hospital social workers went in to ward. It's done slightly differently in acute hospitals with discharge teams often now

So - I cannot comment in your DMs case, this is not legal nor social care advice

But
If she has capacity to decide on discharge arrangements:"/ care plan- she will decide and you don't have a say in that.

But as relqtuves you can say a little bit and share your concerns as that is background they can use in discussions with your DM and in terms of capacity if she understand can retain, weigh up under MCA 2005, as that information is helpful for them to know. Ring the discharge team and ask is a S/w assessing her or can you speak to someone leading her case. Decisions are only as good as Input (information) in that gives a more rounded picture

I won't repeat some of the advice other than to say that threshold level for adult social services / adult community care is £23.250. And that star lifts are dependent on DFG loans which have their own threshold or what someone needs to contribute at what point. Stairlifts are not done prior to discharge as that is a long process.

My first thought is can she have a re-enablement pack wage to go home with if she can do downstairs living if unable to do stairs - that's up to 6 weeks of (multi agency support) including carers support and OTs, but I don't arrangements in your particular area

Time to talk to DM and the ears in more detail - bullet pointed emails are always really useful when you get email addresses from ward of discharge liaison be it hospital S/w or discharge nurse,.