Social Care Support for Patients leaving hospital

Health and Social Care promote a “Home First” philosophy to support and keep people at home for as long as possible.

We want to make sure that people who need help, get the right kind of help. This might be information and advice, signposting to other community services or to step in to support you for a short time, while you recover from your hospital stay.

If you have care needs, a social worker will assess you during your stay in hospital. They will find out how best to support you to return home and keep you as independent as possible. Being in hospital can be a distressing time and you may need support to help you to fully recover once you leave the hospital.

The time following illness can be a time when quick decisions are made about your ongoing care. This is not always the best time to make such decisions, especially if it means moving to a residential or nursing home.

We can help you get back home with care and support in a number of ways and this will give you and your family time to think and make any longer-term plans.

Elderly women looking out of window

Support arrangements that can be made for you


There are several ways in which we can help you to gain or re-gain your independence, including a short period of “reablement”. This is a few weeks of intensive help at home provided by specialist carers and therapists who will work with you to gain or re-gain daily living skills and activities, such as washing, preparing meals, managing your home, and personal care.

Walking with support

A Care Package

You may be able to go home with a package of care which would be tailored to meet your needs. You will have to pay towards your care. You can find out more on our information page. The amount you will need to pay depends on your income, the social worker will tell you more about paying for your care. If you already have a care package and it needs to be increased for a while, the social worker can arrange for this to happen. 

Discharge to Assess Occupational Therapist

The Occupational Therapists in our team will help to assess your needs after you leave hospital. They will support you to regain independence at home with exercises, help re-learn tasks, provide advice on aids and equipment and help to manage risks. If you need any further support they will refer you to our social work team.

Direct Payments

You can organise your support yourself, with a direct payment. This is a way to get a set amount of money each week so you can pay for your own care. As with a care package, you will need to pay towards your care. A direct payment would give you more control over your own care arrangements. We can give a direct payment to your family if they are able to support you in the short term to return home, until we know how to help you in the long term.

Many people need quite a bit of support when they first leave hospital. After they have fully recovered and settled back home, they often don't need as much help and can be much more independent.

Residential and nursing care

We want to support everyone to return home from hospital, if possible. Going from a hospital directly to a care or nursing home is a is a big life decision. We want to make sure that you are given every opportunity to be independent before taking this step, by supporting you to go home first.

Older person talking to younger person

Getting Help

The Hospital Social work team can be contacted via Email: