Discharge care pathway 1

[Lizzypet]

MIL is in a community hospital after multiple falls & eventually breaking her shoulder 2 weeks ago. Discharge in the next few days is being discussed. She will be discharged to her home with carers coming in. She lives alone. Her home is highly impractical - lots of stairs, no downstairs toilet. We had assumed that there would be a visit to her home to assess it & see what changes / equipment needs to be out in place prior to discharge, but have been told (very firmly) that this will not be done. The OT keeps saying that equipment such as commode, handrails etc can be provided but I don't understand what happens if she gets home on day of discharge & it becomes apparent she can't cope there? How quickly could the necessary equipment be provided? We understand that the hospital bed is in demand, but currently she's only walking with supervision, and can't use a frame due to the broken shoulder, & I feel it's almost inevitable she'll fall again & maybe break her hip or something next time. Is this standard procedure or should we be pushing for a home assessment, and if so, who do we escalate concerns to?

It can be a bit of a nightmare. Firstly discharge never happens when they say. But hospital social worker is the person you want to talk to and just insist she can't be discharged without the stuff. They will (ideally) liase with local social services to sort it out.

I assume that you have her house keys?
So she cant just be discharged can she?

I work on a discharge ward and you need to tell them that an imminent discharge could result in a failed discharge. Ask if her home can have an ot assessment. If she’s not safe there on discharge, she’ll end up back in again as a failed discharge, make it clear you have concerns. In my area ot equipment like hospitals beds, commode, bed rails etc can be delivered next day

How quickly could the necessary equipment be provided? In my experience, within hours.

My father arrived home on Friday afternoon. 15mins later an OT arrived and a few minutes later someone from social services. Before the end of the afternoon a couple of zimmer frames arrived, and a perching stool. Visiting carers were set up for the following morning, and meals on wheels from the Monday.

so although it’s better if you can to get everything sorted first, if all else fails, they can move very quickly.

Mind, this was 4 years ago and pre-covid

We had something similar pre covid with my mother when it was patently obvious she wasn't fit to come home. Dad and I spoke to the ward sister about our concerns and that dad wouldn't be able to cope on his own and that did the trick for us.
It doesn't sound like she's safe to come home yet, can they offer a bed based reablement slot (we had to fight very hard to get mum one but we did which bought us another 6 weeks, at the end of which it was blindingly obvious she wasn't and never would be safe to come home and we found a place for her in a nursing home where she absolutely thrived.

It's not clear what stage you're at, she might already be doing the rehab/reablement bit.

The hospital perspective is that if she no longer needs hospital treatment then she should be discharged. There should be a discharge team at hospital who straddle hospital and social care and are responsible for making sure that she is going home to the right care. Nag for contact with them. Be explicit about what you think will happen to your mum if she is home alone, such as the regular falls. It would also help to have a long term view - if your mum is falling a lot at home then it may be that some adaptations will help but it also may be that there need to be bigger changes. What do you think she needs? Would reablement get her back on her feet or would it just be delaying the inevitable?

My mum was discharged and that afternoon a lady came to visit.
It was decided the house needed grab handles, a commode, a raised toilet seat and frame and carers twice a day.

Once mum was told they would arrive anytime between 7am and 10am, and then 6pm to 10pm, she refused them.

She wanted to be more in control and said she would not want to be put to bed at 6pm.

The lady went away and as I type this, not one thing was done. I went and bought a commode and toilet seat/frame. My DH put some handles up.

Mum has since died. The house is being sold.

She ended up in a care home.

It’s been an horrific journey.

Four years ago we were in the same position with my mum. She had serious mobility issues and I was her full time carer. She had been in hospital with sepsis and a perforated ulcer. I was already struggling to cope with her and her lack of mobility and the Carers Society sent me sheaves of paperwork setting out the support we would get to prepare for her coming home. t

Then we had a call from the discharge nurse to say they wanted to send her home with a care package starting sometime the following week. I was told that mum was fully mobile and she agreed. I was told that she could take herself to the toilet and back with a frame which was all the mobility I needed her to have. I was already providing everything else for her. We refused to take her home until there was a care package in place.

The care package materialised a few days later and we collected her but as soon as we got to the car park we realised that we had been misled and it took nearly an hour to get her into the car and the same again at the other end. She could not walk from the living room to the bathroom with a frame and could not get on or off the toilet unaided.

It was days before an OT came to see her and arranged for a commode, perching stool, toilet frame and the hire of a small wheelchair that we could use indoors.

I know now that we should have insisted on OT seeing her home before discharge but when the discharge nurse is telling you that she is fit, mobile and ready and needs to leave before she contracts a super bug and the patient is telling you she is fit and mobile and has no need of rehab what do you do?

Thank you everyone, and sorry to hear that so many other people have had bad experiences. We are still coming up against a brick wall when requesting a pre discharge OT visit to her home. I think that part of the problem is that MIL is desperate to be discharged, so isn't fighting her corner.

Yes I used to be a nurse for a discharge team and unfortunately if she has capacity and is adamant she wants to go home, knowing the risks and that she might not cope, then it is within her rights to go home. Sometimes, and I know this sounds harsh, people have to fail to realise they can't manage x