Patients and carers may have different needs, so as well as contributing (with your permission) to your assessment, your carer can ask for a separate assessment. Hospital staff should not take any support from your carer for granted.
Intermediate care is a time-limited programme that may include health and social care support. It can last for up to six weeks and will have clear goals it is hoped you can achieve in an agreed time.
Intermediate care may be offered following a stay in hospital to help you to return home or to find out if you can manage at home. It can also be offered if providing prompt support could mean avoiding admission to hospital. You can receive intermediate care at home, in a day hospital, community hospital or care home. Services provided are free in England but do not have to be provided for free in Wales.
Rehabilitation usually starts in hospital and also involves staff such as physiotherapists, occupational therapists or speech therapists. It can continue for weeks or even months after you leave.
Drawing up a care plan
To decide what help you could receive, your needs are compared with your local authority’s eligibility criteria. A care plan is then proposed. If you prefer to return home, options that might allow you to do this should be considered before it is suggested you move to a care home. The options might be adapting your home, moving to a more manageable property, or moving to sheltered housing or extra care sheltered housing.
Your care plan may include one or more of the following services – known as community care services – from your local authority: help with personal care – getting up and dressed, bathing meals on wheels – either hot or frozen aids and adaptations to your home – to make basic tasks easier and safer community alarm – so you can call for help if you need it a place at a day centre – offering activities, a hot meal and chance to socialise a place in a care home.
If you are unable to arrange services yourself, social services should make arrangements for you. If you are going home, they can arrange services for you or offer ‘direct payments’ so you can arrange services yourself.
If you disagree with your proposed care plan, discuss your concerns with the person responsible for your discharge. If you remain unhappy, you can make a complaint.
If you cannot contribute to your assessment because of a stroke or dementia, your local authority and the NHS have to make an informed ‘best interests’ decision. Involving your carers as much as possible will help them discover what your wishes would be. If you do not have family who can represent your interests and a change of accommodation is proposed, an Independent Mental Capacity Advocate should be appointed to represent your interests.