Transfer of care out of hospital to home or residential / nursing home
- Refer to Highland's Social Care Admission and Discharge Protocol
- Refer tO the Stroke Unit Admission and Discharge Protocol
Timely planning of discharge should be carried out in consultation with patients and carers. It should be carried out in accordance with NHS Highland’s Joint Health and Social care Admission and Discharge Protocols. Appropriate information should be provided to patients and carers including relevant contact details, including nearest CHSS Stroke Nurse/Coordinator.
Typically, discharge will be appropriate when:
- Patient is medically stable and has an appropriate place to be transferred to
- Community Hospitals should be notified of potential transfers at the earliest opportunity
- AHPs have completed assessment of Home circumstances (if appropriate) and Premorbid function and activities
- Appropriate physical, psychological and social support is in place
- An agreed plan of transfer (including Equipment and Follow Up, Rehab/Support) is in place between the Hospital Team, and Patient and Carers, Primary Health Care Team, Social Services.