Discharge to Assess: What Happens When Hospital Says They Are Ready
Families are often told a relative is medically fit for discharge before anything at home has been arranged, which feels abrupt and sometimes unsafe. The system behind it is called discharge to assess, and understanding it helps you ask for the right things at the right moment. This guide explains the pathways, your rights and what happens when the free period ends.
The principle is that long term care needs should be assessed in the place someone will actually live, not on a hospital ward where everybody looks less capable than they are. So people are discharged once they are medically fit, with short term support, and the full assessment follows at home.
The logic is sound and outcomes are generally better at home. The difficulty is that it can feel like being pushed out of the door, particularly when the family is only told the day before.
The four pathways
Pathway zero covers people who go home with no new support. Pathway one is home with short term care and therapy, which is where most people needing help end up. Pathway two is a short stay in a bedded rehabilitation or intermediate care unit. Pathway three is discharge to a care home for assessment where long term residential care is likely.
Ask which pathway is being proposed and why. If pathway three is suggested and the family wants care at home, say so early and clearly, because pathway decisions are much harder to unpick once a placement has been made.
Pathway 0: home, no new support
Pathway 1: home with short term care and therapy
Pathway 2: short stay bedded rehabilitation
Pathway 3: care home placement for assessment
Ask which pathway is proposed, and say early if you want home
Your rights during discharge
You cannot be discharged to a setting that is unsafe, and a family cannot be compelled to provide care they are unwilling or unable to give. You are entitled to ask what support is being arranged, when it starts, and what happens overnight.
You are also entitled to a Continuing Healthcare checklist where health needs are significant, though under discharge to assess the full CHC assessment is normally done after discharge rather than on the ward. Ask for it to be recorded that CHC should be considered, and keep a note of who you asked and when.
Ask for the discharge plan in writing before the day
Confirm what support starts, at what time, on which day
State plainly if the family cannot provide care overnight
Ask for CHC consideration to be recorded
Request an occupational therapy home assessment where mobility has changed
The free reablement period
Short term reablement or intermediate care is free for up to six weeks and is genuinely valuable. It is therapy led and aims to restore independence rather than simply do things for people, and many people finish it needing far less support than expected.
It is also time limited. The most common failure point is not the reablement itself but the gap that appears when it ends, because the long term arrangement was not organised in time. Start planning for week seven during week two.
What happens when it ends
At the end of the free period a care needs assessment and a financial assessment determine what the council will fund and what you contribute. If you are self funding, you choose your own provider and can start whenever you like.
This is the point at which many families first contact a private provider, often with only days of notice. Reedsfield Care can usually start within 24 to 48 hours of assessment, but a week's notice produces a better matched carer and a properly written plan.
Care needs assessment and financial assessment before the free period ends
Self funders can choose any provider and start immediately
Ask the council in week two, not week six
Continuity matters: try to avoid a gap in support
Review medication against the discharge letter before week one ends
Reducing the risk of readmission
The first fortnight home carries the highest readmission risk. Medication changes made in hospital, reduced mobility, poor appetite and unnoticed infection are the usual culprits, and all four are picked up by someone visiting regularly.
Our hospital discharge support focuses on exactly that window: reconciling medication against the discharge letter, monitoring eating and drinking, supporting the therapy exercises rather than replacing them, and escalating early. Care can usually start within 24 to 48 hours, including at weekends.
Frequently asked questions
Can the hospital discharge someone without care in place?
They should not discharge to an unsafe situation. Ask for the plan in writing and state clearly if the family cannot provide overnight care.
Is reablement free?
Short term reablement or intermediate care is free for up to six weeks, after which a care needs and financial assessment determines ongoing funding.
What if we want care at home but a care home is proposed?
Say so early and in writing. Pathway decisions are much harder to reverse once a placement has been made.
How quickly can private care start after discharge?
We can usually begin within 24 to 48 hours of assessment, including at weekends, though a few days' notice improves carer matching.
Should CHC be assessed before discharge?
Under discharge to assess the full assessment is usually done after discharge, but ask for CHC consideration to be recorded on the ward.
What is the biggest risk in the first two weeks?
Medication changes, reduced mobility and unnoticed infection. Regular visits catch all three before they become a readmission.
