Getting ready to leave the hospital

This page sets out what to expect, what to organise before discharge, and how to ensure you're supported once you're home. 

What to do before leaving the hospital

Your discharge may follow one of four discharge to assess (D2A) pathways, depending on your needs:

• Pathway 0: you’re fully independent and can go home without additional support
• Pathway 1: you need some support at home (e.G. Care workers, therapy, or equipment)
• Pathway 2: you need short-term rehabilitation in a bed-based setting before returning home
• Pathway 3: you have complex needs and may require a longer-term residential or nursing placement

Before you're discharged, the multidisciplinary team will work with you to ensure:

• a clear discharge plan is in place. This includes where you’re going, what support you’ll receive, and who to contact for follow-up
• medication and prescriptions are provided - usually a two-week supply, with clear instructions
• follow-up care is arranged - such as community nurse visits, therapy, or GP appointments
• transport home is organised if needed - including hospital or community transport options
• support at home is set up - such as care workers, equipment, or meal services.

Tip: don’t hesitate to ask questions - the discharge team is there to help ensure you feel confident and informed.                                                                                                                                         

What you should take home with you 

Before leaving, double-check that you have:

• your hospital discharge letter (a copy also goes to your GP)
• any medications or prescriptions (with at least a two-week supply)
• details of follow-up appointments (GP, hospital, or therapy)
• your care plan (if receiving support at home)
• all personal belongings (clothing, glasses, hearing aids, walking aids)

Note: if you're waiting for special equipment (eg, commode, hospital bed), ensure it's delivered before you leave.

Arranging transport home

If you can’t arrange your own transport, ask staff for support. Options may include:

• family or friends - ideal if someone can collect you. 
• hospital transport services - for people with medical or mobility needs (eligibility applies).
• community transport services - some local charities offer low-cost transport for older or disabled adults

Speak to your discharge coordinator as early as possible if you’ll need help getting home.

Preparing your home for a safe return

If you have limited mobility or a change in care needs, a home assessment may be offered. This helps identify:

• establishing your care and support needs in order to maintain your independence - personal care, medication support, or help with daily tasks
• essential equipment - grab rails, shower seats, raised toilet seats, hospital bed
• mobility aids - frames, wheelchairs, crutches

If you need extra support at home

If you’re not fully independent, the hospital team may arrange support through the enablement care team (ECT) or other services. This may include:

• enablement care service (non-chargeable service) - short-term support to rebuild confidence and independence around personal care and daily living tasks.
• community nursing or therapy - for ongoing medical or rehabilitation needs.
• help with meals and shopping - including referrals to meal delivery or grocery support

You may receive a joint home visit within 72 hours of discharge from a D2A assessor and an enablement officer. This visit helps assess your needs and set personalised goals.

What if you don’t feel ready to leave?

Speak up immediately if you're concerned. You should not be discharged if:

• you feel too unwell or unsafe to manage at home
• you don’t have a suitable place to go
• support or equipment isn’t yet in place

Staff must ensure your discharge is safe, supported, and person-centred. You also have the right to request a delay if arrangements are incomplete. 

Understanding the discharge to assess (D2A) initial assessment 

If you’re discharged under pathway 1, you’ll receive a D2A initial assessment at home. This is a joint visit by a D2A professional (nurse, therapist, or social worker) and an enablement officer. It will: 

• assess your current condition and care needs
• identify any therapy or rehabilitation goals
• determine whether you need short-term enablement or long-term care
• set a personalised care plan and timeline

The outcome of this assessment may include:

• enablement only: short-term support with no ongoing care needs
• enablement + supported discharge: for those with therapy goals and potential to regain independence
• double-handed OT + enablement: for those needing intensive support, with the aim of reducing care needs
• long-term care package: if ongoing support is required
• interim care package: for those recovering from fractures or similar conditions
• continuing health care / palliative care: for those with complex or end-of-life needs

Need more help after discharge?

If you need further support once you're home, contact Adult Social Care. They can help with:

• care needs
• home safety
• equipment
• financial assessments for long-term care

Telephone: 020 8314 7777.