Care at Home After a Hospital Stay
Hospital to home care is practical support at home for someone who is leaving hospital and needs help to manage day to day. Protocol Healthcare Services can arrange it across London, the Home Counties and Bournemouth, Poole and Christchurch. We work alongside the person, their family and the hospital discharge team.
Most people go home after a hospital stay, and national guidance in England treats home as the starting point. The first days back can still be hard. Someone may be weaker than before, on new medicines, or using equipment they have never handled. Good planning on the ward, and the right help waiting at home, makes those days safer and calmer.
This page explains how discharge works in England, what the NHS and your council may provide, and where private care from us can fit in. It does not replace advice from the ward team, who know the person's medical situation.
Hospital Discharge in England, Step by Step
Planning starts on the ward
The NHS says discharge planning should happen during the hospital stay, or before a planned admission. The patient and hospital staff are involved, along with family and carers if the patient wants them included. The plan should cover the expected discharge date, where the person will go, how they will get there and any further care they may need. You can read the NHS overview on planning to leave hospital.
Discharge to assess
The Department of Health and Social Care's hospital discharge and community support guidance sets out a model called discharge to assess. The idea is that a hospital bed is a poor place to judge what someone will need in the long run. So short-term care, rehabilitation or reablement is put in place first. Longer-term needs are then assessed once the person has recovered as far as they are likely to.
The four discharge pathways
The same guidance groups discharges into four pathways. Knowing which one the ward has in mind helps you ask the right questions.
| Pathway | Where the person goes | What it usually means |
|---|---|---|
| Pathway 0 | Home, or their usual place of residence | No new or extra health or social care needs. Family or friends may still help with the first few days. |
| Pathway 1 | Home, or their usual place of residence | New or extra care needs, met with support at home such as reablement or a package of care. |
| Pathway 2 | A community bed with recovery support | A short stay to recover before going home or moving on to longer-term care. |
| Pathway 3 | A new care home placement | For people likely to need long-term care. The guidance says it should only be used in exceptional circumstances. |
Private home care from us is most often relevant to pathways 0 and 1. It can also help when someone comes home after a pathway 2 stay.
Intermediate care and reablement
Many people are offered intermediate care after a hospital stay. It is also called reablement, rehabilitation or recovery services. According to the NHS, it is free, follows a needs assessment and usually lasts no more than six weeks, sometimes only one or two. Most people receive it at home from an NHS and social care team that can include occupational therapists, physiotherapists, social workers, nurses and care workers. The NHS explains it in its page on care to support recovery after leaving hospital.
Reablement aims to help someone relearn everyday tasks for themselves, so it may not cover everything a family wants. Some families add private visits for company, meals or a longer morning routine. If you plan to do this, tell the reablement team so everyone knows who is doing what.
When the free short-term care ends
Before short-term care finishes, the team should agree next steps with the person and their family. Depending on needs and finances, the options include:
- ✓A council care needs assessment for longer-term support, followed by a financial assessment
- ✓A carer's assessment for a family member who will be giving regular unpaid care
- ✓An assessment for NHS continuing healthcare where someone has complex, long-term health needs
- ✓Ongoing rehabilitation in the community for some people
- ✓Care arranged and paid for privately, which you can set up with us at any point
If you are paying for care yourself
The national guidance says local areas should give clear information to people who may need to fund their own care, early in discharge planning. It also says nobody has a right to stay in a hospital bed while waiting for a preferred option, so a short-term alternative should be offered instead. If you already know you will pay privately, talking to a home care provider while discharge is being planned gives you more choice. Our paying for care page sets out the funding routes in England.
How We Arrange Care After Discharge
Families, ward staff, discharge coordinators and social workers can all contact us. The steps are the same whoever makes the first call.
- ✓Call while the discharge is still being planned. It is much easier to line up care before a date is fixed than after the person is already home.
- ✓Tell us what has changed. We ask about mobility, personal care, medicines, eating, sleep, memory and the layout of the home. With the person's consent we can also speak to the ward or discharge coordinator.
- ✓Agree a care plan. We write down what help is needed, at what times, and what the person wants to keep doing for themselves.
- ✓Match a Care Professional. Everyone we place has an enhanced DBS check, right-to-work checks, references and training before they start.
- ✓Review as recovery shows. Needs often change quickly in the first weeks home, so the plan can be stepped up, scaled back or ended.
Hospital and social care professionals can send a referral through the form at the bottom of this page by choosing “Professional referral”. Please confirm that the person, or someone legally able to act for them, has agreed to the referral.
Which type of care fits after a hospital stay
- ✓Visiting care suits someone who can manage between calls but needs help getting up, washing, dressing, eating or settling at night.
- ✓Live-in care suits someone who needs help through the day and night, or who is not safe on their own for long.
- ✓Respite care gives a family carer a break during the first weeks, when the strain is often greatest.
- ✓Our private nurse at home page explains that service, for health needs that go beyond help with daily living.
Check that we cover the person's address on our areas page. We cover Greater London, Hertfordshire, Essex, Kent, Surrey, Berkshire, Buckinghamshire, Bedfordshire, Cambridgeshire and Bournemouth, Poole and Christchurch.
What Happens on the First Day Home
The NHS lists several things to make sure of before someone leaves hospital. They make a good checklist for families too:
- ✓Transport home is arranged, whether by family, taxi, voluntary transport or hospital transport.
- ✓The person knows where their house keys are.
- ✓Unpaid carers and care workers know the person is coming home.
- ✓They have the medicines and any new equipment they need, and know how to use them.
- ✓Information about their care has been shared with their GP.
- ✓They know their next steps and how to get help from the hospital.
When we are arranging the care, we agree the first visit with you in advance. Where it helps, we can arrange for the Care Professional to be at the house when the person arrives. On that first visit they help the person settle, check there is food in and the home is warm, and read through the discharge information with the family. They also note anything that looks different from the care plan, so it can be changed quickly.
If the person becomes unwell after getting home, contact their GP, or NHS 111 if you need help and cannot reach the GP. In an emergency, call 999. If the care is not working, ask the council for a review, and tell us so we can change the plan.
Further reading for families
Hospital to Home Care Questions
Common questions from families and discharge teams. If yours is not here, ring the London office on 020 8951 4510 or the Bournemouth office on 01202 016766.
Send an enquiryHospital to home care is support at home for someone leaving hospital who needs help to manage day to day. It can include help with washing, dressing, meals and getting around, and company while confidence returns. We arrange it as visiting care, live-in care or respite care, depending on what the person needs.
Intermediate care, including reablement, is free if you are assessed as needing it. The NHS says it usually lasts no more than six weeks. Longer-term care depends on a council needs assessment and financial assessment, or on NHS continuing healthcare for people with complex health needs. Care you arrange privately with us is paid for by you.
It is the model set out in national guidance for England. Short-term care, rehabilitation or reablement is put in place when someone leaves hospital, and their longer-term needs are assessed once they have recovered as far as they are likely to.
Yes. Discharge coordinators, ward staff and social workers can call us or use the enquiry form and choose Professional referral. We need to know that the person, or someone legally able to act for them, has agreed to the referral.
Yes. Some families add private visits for company, meals or a longer morning routine while reablement is running. Tell the reablement team about the private care so everyone knows who is doing what, and so the person is still encouraged to do things for themselves.
If they become unwell, contact their GP, or NHS 111 if you need help and cannot reach the GP. In an emergency, call 999. If the care is not right, ask the council for a review, and tell us so we can change the care plan.
Planning care for someone leaving hospital?
Talk to us while the discharge is being planned. We will go through what help is needed at home, with no obligation.
Last updated 12 November 2026 · How we write and check our content