Coming Home From Hospital: The Discharge a Carer Has to Plan

A hospital discharge is a handover, and in most cases it is the only one a family carer ever gets. Everything that will go wrong in the first fortnight is decided before the date is set, which is why the work has to start while the person is still on the ward. Getting it wrong is common: 14.7 percent of English discharges in 2024/25 ended in an emergency readmission within 30 days, rising to 17.8 percent among people aged 75 and over (NHS England Digital, Compendium indicator I02040, published November 2025)¹.

Mine was a Thursday in April 2022, twelve days after my mother’s coronary bypass surgery. A nurse told me she was going home and I said that was wonderful. I did not realise those two sentences were the handover. I left with a discharge letter carrying eleven abbreviations, a paper bag of boxes and a leaflet about wound care, and nobody had asked whether there was anybody at the house, whether the bathroom was upstairs, or who was going to do any of this. This article is the list of things I did not know to ask.

If you have arrived here at the start of everything, caring for a parent at home is the map of the whole job, and the first two weeks of caring covers the fortnight that follows this one.

If the operation is still ahead of you rather than behind, what the admission involves shapes everything you will have to arrange afterwards. Thailand Care, a Bangkok-based medical-travel agency, sets out what coronary bypass surgery involves and how long the hospital stay usually runs, which is the part of the timeline most discharge conversations assume you already know.

What should be settled before a discharge date is agreed?

Six things, and every one of them is easier to secure before a date exists than after. Guidance is on your side here, more than most carers realise. NICE and SCIE guideline NG27 requires hospitals to “make a single health or social care practitioner responsible for coordinating the person’s discharge from hospital”, and says that coordinator is “a central point of contact for health and social care practitioners, the person and their family during discharge planning”². Ask for that person by name and write it down.

The six:

1. The named coordinator, and a phone number that reaches them.
2. A complete list of the medicines. NG27 states that people should be given information about their diagnoses and treatment “and a complete list of their medicines” when they transfer between hospital and home, and, if appropriate, that this is also given to their family and carers².
3. What has actually been referred, to whom, and how you will know it has happened. A referral discussed on a ward round is not a referral made.
4. What should make you ring, and who to ring out of hours.
5. Equipment and adaptations, and the date they arrive. A bed downstairs that comes on the Monday is not much use for a Thursday discharge.
6. An honest statement of what you can and cannot do. NG27 requires that where a plan relies on family or carers, the team takes account of their willingness and ability to provide support, their circumstances, needs and aspirations, and their need for respite².

Two further recommendations are worth quoting to anyone who is rushing you. NG27 says plainly: “Ensure that people do not have to make decisions about long-term residential or nursing care while they are in crisis”, and “Ensure that any pressure to make beds available does not result in unplanned and uncoordinated hospital discharges”². If you are being asked to choose a care home by Friday, that sentence is the one to read out.

How do I get the medicines right on day one?

By treating the discharge medicines as a list to be reconciled rather than a bag to be carried home. The single most common failure in the first week is a medicine that was stopped in hospital still being taken at home, or one that was changed being taken at the old strength.

Do three things. Get the complete written list, which NG27 entitles you to². Compare it, line by line, against what is already in the house, and physically separate anything that is not on the new list rather than leaving it in the cupboard. Then ring the community pharmacy and tell them the list has changed, because they are the people who will spot an interaction before anybody else does.

If the list has grown long, ask for a structured medication review. NICE guideline NG5 recommends considering one for people taking multiple medicines, people with long-term conditions and older people, and says the review should take account of the person’s and carers’ views, all prescribed, over-the-counter and complementary medicines and what they are for, and the monitoring needed³. That is a request you are allowed to make. What no page here will ever tell you is what to give or when to change it: that is the prescriber and the pharmacist, and the practical detail of running the round is in managing someone else’s medication.

NG27 also requires the discharge summary to reach the GP within 24 hours, with a copy to the person on the day of discharge². If the surgery has not seen it by day two, ring. Log the call in your care file, with the date and the name of who you spoke to. It changes the answers you get later.

What actually happens in the first 72 hours?

The first 72 hours are the risk window, and the professionals know it: NG27 says a GP or community-based nurse should phone or visit people at risk of readmission 24 to 72 hours after their discharge². If nobody has, that is a call you make rather than a call you wait for.

Three things go wrong most often in those days.

Confusion. New confusion after a hospital stay is usually delirium, not the start of dementia. NICE guideline CG103 records that the prevalence of delirium on medical wards is about 20 to 30 percent, and that 10 to 50 percent of people having surgery develop it⁴. It has an acute onset and a fluctuating course and usually develops over one to two days⁴. It is also frequently missed, particularly the quiet form: CG103 tells clinicians to be “particularly vigilant for changes that may indicate hypoactive delirium, which are often missed, such as withdrawal, slow responses, reduced mobility and movement, worsened concentration and reduced appetite”⁴. My mother spent two days after her surgery not making much sense, and I was told it was probably the anaesthetic. Nobody used the word, and I did not learn it for another year. Delirium or dementia is the article I needed that week.

Falls. Somebody who has been in a bed for a fortnight is weaker than they were when they went in, in a house they last walked around when they were well. Around a third of people aged 65 and over, and around a half of people aged 80 and over, fall at least once a year (NICE guideline NG249, published April 2025)⁵, and the one-year mortality rate after a hip fracture is 31 percent⁵. Walk the route from the bed to the toilet at night, in the dark, before the first night. Falls at home covers the rest, and moving someone safely covers helping without injuring either of you.

Not eating or drinking. Appetite after surgery or a long admission is often poor, and dehydration in older people moves faster than most carers expect. See eating, drinking and weight loss for what counts as a warning sign rather than a bad week.

Is readmission my fault?

No, and the numbers say so. In England, the 30-day emergency readmission rate was 14.7 percent across all ages in 2024/25, and 17.8 percent for people aged 75 and over, on a series running back to 2014/15 when it was 12.6 percent and 17.2 percent¹. In the United States there is no single national all-cause figure under the readmissions programme, but the Medicare hybrid hospital-wide all-cause measure ran at 15 percent for July 2023 to June 2024⁶, and the all-payer all-cause rate held at 13.9 per 100 index admissions from 2016 to 2020, with Medicare patients at 17.0 per 100 in 2020 (AHRQ, HCUP Statistical Brief #304, September 2023)⁷.

I say this because my mother’s readmission arrived out of nowhere and I spent a fortnight going over what I had done. Roughly one discharge in seven comes back. What you can influence is not whether it happens but how fast you spot it, which is the whole point of spotting when someone is getting worse.

What help exists after a discharge, and how do I trigger it?

The mechanism is the same in every system: an assessment produces an entitlement, and the assessment is normally triggered by somebody asking. Ask before the discharge, not after it, because a plan written while a bed is needed moves faster than one requested from home.

The named routes:

• United Kingdom. Ask social services for an assessment of the person’s needs, and separately for a carer’s assessment in your own right. The Care Act 2014, section 10, requires the local authority to carry out a carer’s assessment where somebody provides or intends to provide care and appears to have any level of need for support⁸. Hospital discharge teams can start both. Where the need is a long-term complex health need rather than a social one, ask specifically about NHS Continuing Healthcare, which is covered in paying for care and what you can claim.
• United States. Medicare home health can cover part-time or intermittent skilled nursing, physiotherapy, occupational therapy, speech therapy, medical social services and home health aide care where skilled care is also being received, for somebody who is homebound and certified as needing it, from a Medicare-certified agency⁹. “Part-time or intermittent” means roughly up to 8 hours a day combined, to a maximum of 28 hours a week⁹. The sentence carers most need is what it does not cover: 24 hour a day care at home, meals delivered to the home, homemaker services unrelated to the care plan, and custodial or personal care when that is the only care needed⁹.
• Australia. My Aged Care is the single entry point to government-funded aged care, and it carries out the assessment that establishes eligibility and the right type of care¹⁰. Carer Gateway is the parallel route for you, with counselling, peer support, carer needs assessment and support planning, and tailored support packages including planned and emergency respite¹¹.
• Canada and Ireland. Home and continuing care is arranged through provincial and territorial health systems in Canada and through the health service locally in Ireland, so the named service varies. The question that works in both is the same: who assesses eligibility for home support here, and how do I make the referral.

Whichever system you are in, getting help in maps what exists and what each part is actually for, and the care needs assessment and the carer’s assessment cover the two assessments in detail. If paid visits are going to be part of the plan, choosing a home care agency is the vetting method.

What to write down, and how to be heard

Keep one folder and start it on the ward. The discharge letter, the medicines list, the name of the coordinator, the date and time of every call, who you spoke to and what they said they would do. NG27 requires that the discharge plan includes the person’s condition, medicines information, contact information after discharge, arrangements for continuing social care and health support, and details of community and voluntary services, and that it goes to everyone involved in ongoing care “including families and carers”, with consent².

The folder is not administrative tidiness. It is the difference between saying “I think somebody referred her” and saying “the referral was made on the fourteenth by the ward sister, and I am ringing because it has not arrived”. Keeping a care file sets out how to build one, and being heard in appointments covers the ten minute slot where you have to use it.

This is a call today, not something to watch overnight

In the first fortnight after a discharge, ring the same day if:

• They are more confused than they were yesterday, or the confusion comes and goes through the day. Say the word confusion.
• They have had a fall, even one they got up from.
• They have stopped eating or drinking, are unusually drowsy, or their urine has gone dark and scant.
• The wound is redder, hotter, more painful, or leaking, or they have a fever.
• New pain, worsening pain, or agitation in somebody who cannot tell you what hurts.
• They are more breathless than yesterday, or their ankles or belly have swollen quickly.

Who to ring: in the United Kingdom, the GP surgery, the ward if you are still within their stated readmission window, or NHS 111 out of hours. In the United States, the discharging hospital’s number on the discharge paperwork, the person’s doctor’s office, or the nurse line their plan runs. In Australia, the GP or healthdirect on 1800 022 222. In Canada, the family doctor or the provincial health line, 811 in most provinces. In Ireland, the GP or the out of hours GP service.

If breathing changes suddenly, there is chest pain, one side goes weak, speech changes, or there is bleeding that will not stop, use the emergency number immediately: 999 or 112 in the United Kingdom and Ireland, 911 in the United States and Canada, 000 in Australia. Nothing on this page is a reason to wait until the morning.