Any experience of hospital to care home discharge please.

Luckygirl3

Care to be Different is linked to a firm of solicitors who plug their services there. Their basic information pages are very useful though.

All the advice on there is free. I never paid a penny to Care to be Different or anybody else. They publish a hefty book covering absolutely everything but I didn’t buy that either. But I know several people who have and it guides you the whole way through the process. I just read through the site, realised I could use the Fasttrack way and secured the funding all within a week.

I don’t know anything about solicitors on there because I did it myself. Like I said, even the GP had never heard of NHS Continuing Health Care so I explained it to him. Best kept secret!!

I'm sorry that you are in this distressing situation, Jellybaby.
Similar to my 86 year old brother-in-law, 8 weeks ago he was admitted to hospital after a fall, no broken bones but a bashed face & shaken up badly. His family expected him to be checked over & sent home. He spent 15 hours in A&E, admitted to an overflow/holding ward for the next 4 days, then onto a ward for elderly. By then he had gone from no signs of any type of dementia to almost completely delusional. He, too, later contacted Covid on the ward. (leading to 12 days of no visits.). He has lost a lot of weight & muscle.
Until his fall he had been an active, sprightly man, enjoying working in his large garden.
His family are at their wits end, not knowing what they are going to find on their visits.
I don't know what will happen to him, this is not the way he (or anyone) would choose at the end of a long busy life.
I'm sorry for my long, "sorry for my own family", post.

I do hope you find a solution for your dear mother, Jellyfish.

That should be "leaves hospital" wish there was an edit key

Jellybaby71011 you have my complete sympathy. Several years ago my mums's story was so much like yours, except she went into hospital from her own flat completely able to care for her self and she had the very best care in hospital.
So a few things I learned.
Firstly the effects of a UTI can persist long after it has been cleared, but your mum should be being tested to ensure it has cleared.
Secondly you should ask for a team meeting (we had regular ones)present should be someone from the nursing team, someone from orthopaedics, a physio, the dietician if she still isn't eating, the social worker, a geriatric specialist and you and anyone you choose to accompany you. If your mum is able she should be there as well. The team should update you on treatments, possible outcomes and the proposed way forward.
If your mum needs nursing care they should have a list of care homes that can provide that.
When your mum needs hospital she is entitled to a period of (I think) 6 weeks free care in a home as a hospital discharge patient.
My mum never fully recovered from her pelvic fracture and would have been immobile. She needed a home with a hoist to enable her to be lifted from her bed.
I still can't decide if her unexpected death from pneumonia was a blessing or not. It shocked everyone including her nursing team. I hope this doesn't upset you but I thought you should know.
Hope you get things sorted for your mum. It is so distressing to see the deterioration that can happen in hospital.

We’ve looked at care homes already. And chosen our top 3. None of them have nursing care though as we were advised she’s been classed as residential. We need to check that they can cater for my mums increasing needs as I wouldn’t want her moved again quickly.
I’m learning a lot on here.
The lovely mum who six weeks ago was still ordering her Alexa about. Choosing what tv channels to watch. Talking to friends on the phone. Getting herself ready for bed. Eating well has become a confused sad bewildered old lady. Incontinent for the first time in her life.
It’s so painful to watch. We visit twice a day but quite often she’s asleep. I can never decide if that’s preferable to the delirium which is so distressing for us.
I know loads of people on here are probably going through/have gone through the same as us.
You just want their last days to be as good as possible.

Watching with interest as we are in exactly the same position with my mil. Thanks to everyone for your comments. I am reading everything. Good luck Jellybaby.

I don't know whether this would help you, but I every hospital is supposed to have a PALS (Patient Advice & Liaison Service) which offers "confidential advice, support and information on health related matters" and a "point of contact for families and carers". See www.nhs.uk/nhs-services/hospitals/what-is-pals-patient-advice-and-liaison-service/
PALS were helpful to me when an elderly relative was in hospital in 2021 and (despite an LPA being in place) I couldn't access the most basic information from the Ward staff.

This was my mum's situation after a stroke and a bowel resection. It seems that you need a nursing home rather than a care home. As others have said the first 6 weeks are free, after that, depending on your mother's financial situation she or her local authority will be liable for the care part, while the NHS picks up the nursing element think upwards of £1,2K per week, min. You can apply for 24 hr attendance allowance for her, now, and then try your luck at CHC, which covers all costs, but the NHS will do everything they can to reject this unless your Mum is at end of life care. My advice would be to get your social services advisor on side as they can help access a decent home. Go look at the Nursing home - look at the CQC website for the ones with a 'good' rating and simply refuse to let your mum be moved out to anywhere you do not like. The best places, private or council, all have waiting lists. We were lucky and found an excellent nursing home where the care was far superior to anything she had in the hospital and they resolved at lot of her issues by simply having the time and experience of elderly, ill patients.

After my 93 year old mother fell and broke her shoulder, she was in hospital for two weeks and then discharged into a lovely care home where she remained for the next three months at the expense of the NHS. Your mother is entitled to at least six weeks of care provided by the NHS or SS. This can be care in her own home, which clearly wouldn’t be suitable, or care in a suitable facility. Good care homes offer both nursing care and social care, and whilst some residents are active and join in with all the activities on offer, many are not, and are wonderfully cared for in their beds, in their rooms. When my mother’s funding stopped, it was absolutely clear that she would be unable to return to her sheltered apartment, even with carer visits several times a day, and so we looked for, and found, an absolutely lovely care home, which she moved into and she stayed until her death, some ten months later. She was almost exclusively cared for in her room as she was increasingly disinterested in joining in any activities and she just enjoyed her family visiting her. About a week before she died, the paramedics were called because her sats were not stable, but then they settled. When I was told, I asked that mum wasn’t to be taken to hospital. I knew that she was moving towards her death and I didn’t want the hospital to start poking, pricking, testing etc to no avail. She was by then 94, nearly 95 years old. I wanted her to be able to die in her own room, cared for by people she knew. She died peacefully six days later.

Again thank you all.
I’ve cared for my mum in my house for the last 4 years.
We’re very likely now to be in the last days/weeks /months.
I just want her to be properly and lovingly cared for. And to not have to fight for it!
I’ve looked up all the links you’ve mentioned.
And feel a little more prepared.
We’re going to ask for a full geriatric assessment as a first step.

Care to be Different is linked to a firm of solicitors who plug their services there. Their basic information pages are very useful though.

Hospital staff will first deny that it's needed, resist doing assessments - then fail to complete the forms with accuracy - so beware, you need iron determination and people on your side.

Indeed so. I had worked in the field and absolutely refused to let them pull the wool over my eyes. Sometimes they do the "checklist" (that leads to full assessment) unbeknownst to anyone and, since the whole system is very complicated and they are not trained in it, they get it wrong.

The link should be: www.beaconchc.co.uk

They were brilliant with me and free! And eventually I got the funding for OH. They only charge if you find yourself in an appeal situation. All the initial advice is free.

Beware sites that charge - solicitor firms have jumped on the bandwagon.

I’m sorry Jellybaby, what a distressing situation for you.
I’m glad that you’ve had so much good advice.
and a bump up the list, for some more reason

I think your mum being assessed by the Care of the Elderly team should be the priority * Jellybaby71011*. Orthopaedic team nurses are not experts in that field, their priority has been caring for her fractured pelvis.
She needs a full geriatric assessment before any decisions can be made about her future, it’s too soon for any consideration of care home placement or continuing healthcare funding before that has been done. I would put your concern that she has not been appropriately assessed by care of the elderly into writing, and formally hand it to the nurse in charge when you next visit, say you feel a best interest meeting cannot take place until the assessment has taken place. As she showed no sign of dementia before admission that is more relevant than an assessment by the mental health team at this stage, they will ask for mental health involvement if they cannot treat her condition successfully.

There are solicitors that specialise in gaining CHCF on a no-win, no-fee basis. Hospital staff will first deny that it's needed, resist doing assessments - then fail to complete the forms with accuracy - so beware, you need iron determination and people on your side.

Still, I can't see how a care home would accept somebody who refuses to eat, is often sick - and mainly asleep. Don't be bullied into accepting an arrangement that isn't suitable and ask for the six weeks 'rehabilitation' - in a hospital environment.

PS The link in Luckygirl’s post is incorrect.

The best place to look is Care To Be Different.

Luckygirl3

In her condition she will qualify for Continuing Health Care Funding from the health authority - insist that she is fully assessed for this, possibly under their end of life rules. Check it all out at www.beacon.co.uk.

Sadly it is not unusual for elderly or sick people to become delusional and disoriented after surgery following trauma. My OH had Parkinsons and fell and broke his hip - after the op he was totally paranoid and delusional and it continued until he died 10 months later.

Not easy to get but once you know your Mum is on end of life care you can apply via the Fast Track route.

The hospital did their level best to avoid getting CHC and marked my Mum down on all the scores.

I got the forms myself, filled in as much as I could so there was less for GP to do and dropped them in marked urgent. The GP rang me and said he had never heard of this before!! I did my best to explain and told him when he had signed them I would personally collect them and see they got to the correct place.

I got the funding within a week which was for about 2 months care until she passed away. Poor old Mum!

In her condition she will qualify for Continuing Health Care Funding from the health authority - insist that she is fully assessed for this, possibly under their end of life rules. Check it all out at www.beacon.co.uk.

Sadly it is not unusual for elderly or sick people to become delusional and disoriented after surgery following trauma. My OH had Parkinsons and fell and broke his hip - after the op he was totally paranoid and delusional and it continued until he died 10 months later.

Thank you everyone for your kind replies.
Amazing similarities cornergran with your friend.
I’m trying to arm myself with information, resolve and determination. And the more advice/opinions I get the better it will be.

Our friend was in almost exactly the same situation after admission with a broken hip. Her daughter made a fuss and didn’t stop until there was a proper, detailed assessment of her Mum’s needs. It was a hard fought outcome involving an official complaint and several meetings with senior hospital staff.

In an orthopaedic ward our friend experienced covid, several UTIs and went through a period of refusing food. Sudden discharge was raised because the broken hip that took her there had mended. The needs of rest of the person were totally overlooked

Once assessed properly it was possible for our friend’s needs to be understood, she was transferred to a rehabilitation unit and from there to a self funded nursing (not care) home identified and a transfer effected. This all sounds very smooth, it wasn’t and wouldn’t have happened at all if her daughter hadn’t persevered .

Some months later our friend is happy and comfortable, relaxed and eating well. In her case there was and remains an element of dementia. This became so much worse in hospital, anaesthetic seemed to trigger a worrying leap forward of symptoms. I’m happy to say now settled she is cognitively much more stable. It was a frightening time for her and those who love her. We visited and left believing she wouldn’t survive.

Please don’t hold back jellybaby, with POA you are entitled to speak on your mothers behalf and push for what is best for her, not the hospital. Wishing you the best outcome it can be.

I agree with primrose53 you fight for her rights she’s in no state to do this herself. Shout loud and refuse her leaving hospital till properly assessed. Good luck.

Where does your Mum normally live?

Do not allow them to send her anywhere without a Care Plan in place. I wouldn’t worry that she might be called a bed blocker. If the hospital and social worker get their act together and find her a nursing home she won’t be blocking anything. She is entitled to 6 weeks free care when she leaves hospital.
Best wishes to you both.

With regards to not being too demanding, that's exactly what you do need to be. From what you are saying she does need nursing care. I would suggest that you contact homes in your area and find out if they will take her and then you will need to sort out finances. You will need to visit the homes and make your own minds up as to the level of care they are providing. It would be a good idea to contact social services for some advice too. She probably needs to have a social worker appointed.
I would also think that age concern may be able to help you further. Your mum needs an advocate and it looks like it's you so you will have to do your research and be prepared to stand your ground in the best interests of your mum. Good luck.

I have a friend who was recently in a similar situation to you. She managed to get her mum into a hospice, she did a lot of ringing round, it did take quite a few days to sort out, but she was transferred by ambulance. Sadly she passed away 10 days later. But she was cared for very well. Good luck