When you're ready to leave hospital, your stroke team will work with you to agree what support you will need and put together a discharge plan. This will cover the arrangements for your continued rehabilitation and care at home, or in a rehabilitation centre or care home. Arrangements include the community services that will be helping you and any equipment you need.
You shouldn't be sent home from hospital until your stroke team has assessed your immediate needs.
On this page:
- Care needs assessment
- Hospital discharge frequently asked questions
- Other things to bear in mind
- Your community stroke team
Care needs assessment
If you're likely to have longer-term care needs, a care assessment should be completed with you to work out what help and support you need. When you have an assessment, be honest about your needs.
- In England and Wales, this is called a ‘care needs assessment’.
- In Scotland this is called an ‘assessment of your care needs’.
- In Northern Ireland, this is called an ‘assessment of need’ or a ‘health and social care assessment’.
If you are likely to need changes to your home or new accommodation, you may also have a home needs assessment.
You should be fully involved in decision-making. If you find it difficult to understand your care or express your opinions, an advocate can be appointed to represent you in discussions. We have details on advocacy support. If you’re unhappy with the outcome of a needs assessment, contact your local council about their complaints procedure.
What does the assessment involve?
The care assessment will usually look at your physical, psychological, social and cultural needs. It might recommend things like getting help from a paid carer or adaptations to your home.
The support you need should be included in a written care plan, which you’re entitled to a copy of.
Who does the assessment?
In England, Wales and Scotland, the social services department of your local council is responsible for the care and support needs assessment, but they sometimes ask other organisations to carry out the work. Different professionals may be involved in making an assessment, including a social worker and an occupational therapist.
In Northern Ireland, the local Health and Social Care Trust carries out the review of your social care needs.
When does the assessment happen?
These assessments should happen before you leave hospital as part of the discharge process, but sometimes they happen afterwards. If an assessment was not carried out, or if you develop new support needs some time after a stroke, you are entitled to have your needs reassessed. You can contact adult social services at your local council if you have not received an assessment, or if your needs change.
Intermediate care
As part of assessing your needs, social care professionals should consider if you'd benefit from intermediate care services and reablement services.
What is intermediate care?
Intermediate care is short-term intensive support that aims to help you recover and increase your independence. It can be provided in a community hospital, care home or your own home.
A mix of health and social care professionals will help you set and reach achievable goals and relearn skills. The team might include nurses, social workers, doctors, and a range of therapists.
What is reablement?
Reablement is a type of intermediate care. It focuses on helping you re-learn skills needed for daily living. Social care staff support you at home by observing and guiding you to complete tasks such as washing, dressing and cooking a meal, rather than doing these tasks for you. The aim is to help you live independently.
How long will it last and do I have to pay?
If you’re eligible and this service is available in your area, you’ll receive up to six weeks of reablement care after hospital discharge for free. However, most people usually receive intermediate care including reablement services for one to two weeks.
Towards the end of your intermediate care or reablement, staff consider if you’re likely to make further progress. If you need care for longer than six weeks, you might have to pay for it.
If you're unlikely to benefit from further reablement support, another care needs assessment should be carried out to see if you need social care or NHS support in the long-term.
Involving your unpaid carers
If you have family or friends caring for you, they should be involved in discussions about your discharge and support needs.
Following the care assessment, you, social services, health professionals and your family, where relevant, will decide if you need any community care services. If necessary, the health and social care professionals team will put together a package of support for you.
Your social worker also needs to ensure that if friends or family are helping to care for you, they get the right support too. Any friends or family members providing unpaid support can have a carer's assessment to see if help is available.
Hospital discharge frequently asked questions
You may need to pay towards the costs of social care. This can vary depending on where you live in the UK.
However, health care, which includes physiotherapists, occupational therapists and speech and language therapists, comes under the NHS and this support is free.
Intermediate care, including reablement services, is free for up to six weeks. If you need this support for longer than six weeks, you might have to pay for it.
If your care plan suggests you need care services in your own home, a financial assessment(means test) decides how much funding you receive and how much you will pay yourself. If you’re eligible for homecare services, this may be provided by the council. You may be able to arrange it yourself, with funding from direct payments or a personal budget. Home help and care is available from private providers and charities.
Yes, care plans are reviewed. The local authority must check the support is still right for you. This usually happens within a reasonable amount of time after discharge. After this, your care plan should be reviewed at least once a year, or more often if needed.
If, at any point, you find the support you are receiving isn’t suitable, you should contact social services and ask for a review of your care plan.
People move into a care home for different reasons. If you’re not able to look after yourself safely or manage on your own overnight, or cope between visits from a carer, you might need to go into a care home. Sometimes, people go into a care home temporarily.
The thought of moving into a care home can feel like a big change and very frightening. In particular, you may worry about losing your independence. We have information to reassure you and help you to make the right choice, including types of care home, things to consider when choosing a care home and paying for accommodation.
The NHS has produced a series of leaflets to give you more information on what happens when you leave hospital:
Other things to bear in mind
- You can arrange your own home care, if you are not assessed as being eligible for support from your local authority. You should be given information and advice from your local council’s social services department to help you arrange this.
- People with long-term, complex health needs may qualify for NHS continuing healthcare. We have more information on this.
Your community stroke team
Your community stroke team will help you with your continued care and rehabilitation once you leave hospital. Like your hospital stroke team, your community team will be made up of different healthcare professionals, including:
- Community stroke nurses.
- Physiotherapists.
- Speech and language therapists.
- Occupational therapists.
- Dietitians.
- Psychologists.