Transfer of Care Hub

Illustration of a patient in a hospital bed, a house and a patient sitting on a char talking to a therapist stittli

Hospital Discharge Support: Working together to get you home

When you no longer need hospital care, it is better to continue your recovery in your familiar place of residence. 

Staying in hospital for longer than necessary may reduce your independence, result in you losing muscle strength, and increase your exposure to infection.

Our Home First approach aims to support as many people to return to their usual place of residence as soon as possible.

What is the Transfer of Care Hub?

The Transfer of Care Hub is comprised of NHS and social care, working with local charities and partners to plan care that is right for our patients.

Our team will arrange any care and support you may need to help you return
home. This may include medical follow-up, rehabilitation, or practical assistance such as help with dressing, bathing, or preparing meals.

We aim to make sure all discharges are completed safely and without unnecessary delay, as remaining in hospital longer than needed can increase the risk of infection.

Occasionally, unexpected delays may occur or new options may become available at short notice. We will always try to give you and your family as much notice as possible about your discharge plans. 

When going straight home isn't possible

In some situations, returning home immediately may not be suitable. This may be due to changes in your home environment, your rehabilitation needs, new or complex nursing requirements, or care needs that cannot be safely managed at home.

If this is the case, you will move to the most appropriate accommodation to support your recovery. This is usually a temporary arrangement while your discharge assessment is completed and longerterm plans are agreed.

Paying for care

Local authority care services are chargeable. You may be asked to contribute
towards the cost of your care, depending on your circumstances. A financial
assessment will be carried out to determine any contribution required.

Assessment at home

Soon after your discharge, a health or social care professional will visit you at home or alternative accommodation to plan for your ongoing care needs,
this may include linking you to support from voluntary, community or faith organisations.

Download this information as a leaflet:  TOCH Patient Discharge Leaflet.pdf [pdf] 704KB