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Our Hospital Discharge Team

Helping your safe transition between hospital and home

If you are an inpatient in hospital, the Hospital Discharge Team will provide support and guidance to help you make a successful and safe move back into your own home or an alternative placement (eg, rehabilitation or discharge to assess).

The Hospital Discharge Team provide comprehensive assessment and case management support to individuals in hospital to facilitate a safe discharge.

The team work closely with NAViGO (Mental health services) and Diana Princess of Wales Hospital to support people and promote their independence, re-enablement, health and wellbeing.

The Hospital Discharge Team act as co-ordinators of the various care professionals and support agencies that need to be involved in the decision making, with you and your family, as to the best way to continue your care following discharge from hospital, through your recovery and ideally back into your own home.

What does the service include?

  • Combined review of health and social care needs
  • Direct access to Recovery and Recuperation short stay placements
  • All individuals will have a case manager who will be responsible for their discharge out of hospital, through the recovery and recuperation service. Onward referral to the following: (depending on the patient’s pathway from hospital)  Focus, Intermediate Tier Therapy, Intermediate Care at Home, CPG (Cambridge Park) and Continuing Health Care (CHC).
  • Reinstating, new or increased packages of care
  • Provide and offer advice and guidance about other community services and signpost you to other services
  • Arranging equipment to enable safe discharge
  • Close liaison with community services

The Hospital Discharge Team is made up of Discharge Nurse Practitioners. It is available to adults residing in North East Lincolnshire.

What if you are not able to move home immediately?

If, following your assessment you aren’t able to remain at home, you may be offered a short-term placement in a residential care setting or an enhanced recovery bed in the community.

If this is the case, throughout your stay you will be participating in your individual care plan that we have designed to promote and maximise your independence with the ultimate goal of getting you back into your own home.

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