Hospital discharge is where a great many families first encounter the care system, usually at short notice and usually under pressure to free a bed. Decisions made in that window have a habit of becoming permanent.
This guide covers how discharge works in England, what you’re entitled to, what’s free, and how to get support in place quickly without agreeing to something you’ll regret.
How hospital discharge works now
Most areas, including West Sussex, use a Discharge to Assess model. The principle: people are discharged once medically fit, and their longer-term needs are assessed afterwards, at home, where the picture is more accurate.
The logic is sound. A hospital ward is the worst possible place to judge what someone can do — unfamiliar, disorienting, and deconditioning by the day. Assessing at home produces better decisions.
The risk is the handover. If short-term support isn’t properly arranged, “assess at home later” becomes “discharge and hope”, and families discover the gap at 8pm on a Friday.
What should happen
- A discharge coordinator or therapy team assesses readiness
- Short-term support is arranged — usually free reablement
- Equipment is delivered or fitted before or on the day of discharge
- A longer-term assessment happens at home within days
- An ongoing care plan and funding decision follow
Your rights at discharge
Worth knowing, because they’re frequently not volunteered:
- You cannot be discharged without a safe plan. “Safe” includes getting into the house, getting upstairs or to a bed, food, and managing medication.
- Family cannot be compelled to provide care. If you can’t, say so plainly and early. Assumptions made on the ward about what a daughter will do tend to harden into the plan.
- Carers must be consulted about a discharge that affects them, and have a right to their own carer’s assessment.
- You can decline an interim care home placement if home with support is feasible — though you’ll need to show how it works.
- Ask for an NHS Continuing Healthcare checklist if health needs are substantial. CHC is not means-tested and pays 100%. It is much harder to obtain once someone is settled at home, so ask before discharge. See the funding guide.
- You don’t have to decide about a care home from a hospital corridor. Request short-term support and decide properly. This is the single most important sentence in this article.
What’s free, and for how long
| Support | Cost | Duration |
|---|---|---|
| Reablement (local authority) | Free, not means-tested | Up to 6 weeks |
| Intermediate care | Free | Usually up to 6 weeks |
| Equipment via OT | Free | As needed |
| Community nursing | Free (NHS) | As needed |
| NHS Continuing Healthcare | Free, not means-tested | While eligible |
| Ongoing home care after that | Means-tested or self-funded | Ongoing |
The six-week cliff edge catches families out constantly. Ask in week two what happens in week seven — not week six.
Preparing the home before discharge
- Heating on, food in, and milk. Coming home to a cold house with an empty fridge undoes a lot.
- Can they get in? Steps, a heavy door, a key safe if carers are coming.
- Can they get to a bed and a toilet? If stairs are now a problem, set up downstairs before the ambulance arrives, not after.
- Clear the routes — rugs, clutter, trailing flexes.
- Check the equipment arrived and that someone has shown you how to use it.
- Get the medication list and understand what’s changed. Discharge medication changes are a common source of error and readmission.
- Know who to call out of hours, and write the number somewhere visible.
The first two weeks
This period determines a lot. Readmission risk is highest here, and so is the opportunity to recover properly.
- Expect them to be weaker than you anticipated. Strength falls fast during bed rest, and the drop often surprises families who saw someone walking in.
- Encourage movement early and often, within whatever the therapy team advised. Sitting up, standing, short walks indoors.
- Prioritise protein and fluids. Appetite is often poor; small frequent portions work better than meals.
- Watch for infection — new confusion, fever, pain on passing urine, a wound looking worse. Sudden confusion in an older person warrants a same-day GP call.
- Book the GP review within a week or two, especially if medication changed.
- Don’t do everything for them. The instinct to take over is strong and slows recovery. See how reablement works.
Arranging private support quickly
Council reablement is free, but capacity is finite and there can be a wait. Families arrange private care after discharge when:
- Support isn’t available on the discharge date and the alternative is an unsafe night
- The free six weeks have ended but recovery is still progressing
- More intensive input is wanted than the standard package
- Night-time cover is needed and isn’t part of the offer
- The family carer is working and can’t fill the gaps
a CQC-registered agency can usually start within 24 hours and same-day for urgent discharges. We work alongside council reablement rather than replacing it — often covering evenings, weekends or nights around the free service.
Frequently asked questions
Who arranges care after a hospital discharge?
The hospital discharge team coordinates it, usually with the council’s reablement service and community therapy. You can also arrange private care yourself, in parallel, if the NHS package doesn’t cover everything or can’t start in time.
Is care after hospital free?
Reablement and intermediate care are free for up to six weeks in England and are not means-tested. Equipment and community nursing are free. Ongoing home care after that period is means-tested or self-funded, unless NHS Continuing Healthcare applies.
Can a hospital discharge someone who isn’t safe at home?
No. A discharge must have a safe plan covering access to the property, sleeping, toileting, food and medication. If you don’t believe the plan is safe, say so to the discharge coordinator and ask for it to be recorded. Escalate to the ward manager or PALS if needed.
How quickly can private home care start after discharge?
Often within 24 hours, and same-day for urgent cases. Call as soon as a discharge date is mentioned rather than on the day, so an assessment can happen before the person comes home.
What if we can’t care for them ourselves?
Say so clearly and early. Family members cannot be required to provide care, and discharge plans built on an assumption nobody checked are a frequent cause of readmission. You also have a right to a carer’s assessment in your own name.
The Care Panel is an independent publication. We are not a care provider and are not regulated by the Care Quality Commission, because we do not deliver care. Always check a provider’s own CQC registration and inspection report before you commit.
Written and fact-checked by The Care Panel. Last updated September 2026. General information, not medical advice.