Assessing your needs following discharge from hospital

Discharge to Assess (D2A) 

Health and social care partners across Wolverhampton are committed to ensuring that you are discharged from hospital as soon as it is safe to do so.  Research shows that people recover better at home and any longer hospital stays can lead to increased risk of falling, lack of sleep, catching infections and physical decline.  We want to help you leave hospital as soon as your treatment has been completed. Your recovery can continue in the community. 

As soon as you are becoming ready for discharge the hospital staff will speak to you and your family about what you are able to do for yourself. If it is felt you need support with day-to-day living the ward will share this information with our team of health and social care professionals who will agree the right discharge plan for you.

Home first

In Wolverhampton, we operate a ‘home first’ approach when you are ready to leave hospital, because for 95% of people, home is the right place to go, to recover or have further health and care support.

This means wherever possible, you will return home and with support if required. If you are unable to return directly home it might be necessary for you to move to a temporary care setting for further recovery, rehabilitation and reablement. In a small number of cases a nursing and residential home may be the most appropriate place if returning home is highly unlikely due to your ill health or care and support needs being too complex.

Hospital based Social Workers

In Wolverhampton, hospital-based social workers play a vital role as members of a discharge team. Their role in hospital is particularly essential for people whose social circumstances are complex. They ensure a person-centred and strengths-based approach is adopted to support your discharge. 

Assessments and decisions about long term care are made outside of the acute hospital. Our social workers are experienced in supporting people to make informed choices, weighing up the risks and benefits of options, and they are familiar with mental health, mental capacity and safeguarding issues. They will also be knowledgeable about carers’ rights. They will discuss your care and support needs which will include a financial assessment if any financial contribution is required. They also have access to range of advice and information should additional help be required.

Hospital Discharge Pathways

In Wolverhampton, we offer the following pathways to support you on your journey to recovery:

• Pathway 0 – discharge home
  • No formal input from health or social care needed once home. Including people who return home with no change in their care needs.
     
• Pathway 1 – discharge home with a new or increase in health or social care needs
  • Support to recover at home or your usual place of residence.
     
• Pathway 2 – discharge to a community bed-based setting
  • New or additional health and/or social care and support is required in the short-term to help you recover in a community bed-based setting before you are ready to either live independently at home or receive longer-term or ongoing care and support.
     
• Pathway 3 – discharge to a new bed-based setting
  • Require ongoing 24-hour nursing care, or opportunity for recovery from delirium or unable to weight bear following a fracture, in a bedded setting.

Only in very exceptional circumstances would a person be discharged into a permanent care home placement.

People discharged into pathway 1, 2 or 3 will be connected to appropriate community health and social care services to support their recovery, rehabilitation and reablement.

For more information please view Planning together: leaving hospital when the time is right also available in Easy read version .

If you have any concerns about your care needs please contact us.