Patients may live or be discharged to a variety of social care settings and understanding these is important for any resident doctor. This can help you have conversations with patients and their families about services patients may already have in place on admission or will have on discharge.
If you’re looking to understand the multidisciplinary team members roles, including reviewing funding and eligibility, have a read of our article on Discharge Planning.
Contents
Independent Living & Sheltered Housing
These are often flats or bungalows designed for older people to live independently whilst giving them an added layer of safety. Individuals have their own private flat and are responsible for living costs. They differ slightly from a private house, as they often have a call system to summon emergency help if needed but staff do not provide direct, on-site support. A member of staff may check in daily with a phone call or through an intercom system. Some schemes have day rooms with social activities for residents, although these are resident-led. There is often a minimum age and application process involved.
Supported Living
Supported living or Assisted living is the next step from independent living. These schemes again consist of independent flats where individuals are responsible for their own tenancy and living costs, but there is support available. A team of support staff assist residents with varying levels of support available. Usually, help is provided with domestic tasks such as shopping and laundry, whilst some schemes include communal meals. All flats are self-contained with social areas and organised events for residents to socialise when wanted. There is usually a member of staff on-site 24hrs a day with an emergency call bell provided in each flat. These services aren’t regulated by the Care Quality Commission.
There may also be the provision for providing personal care, which may be delivered via an in house or external service. Often there is a maximum limit provided by in house carers (generally 21 hours per week) which external agencies can then extend. Any personal care provided is regulated by the Care Quality Commission.
Patients may use the terms Supported Living/Assisted Living/ Independent Living/ Sheltered Housing interchangeably therefore it is important to clarify exactly what is provided for them, as this may affect discharge planning.
Care Home
Patients often use this term and as professionals, it can be difficult to establish exactly what they mean.
This umbrella term includes many different forms of care but the main distinction to make is that of a Residential home versus a Nursing home. Care homes can be run by private companies, charities or sometimes by councils.
Practical Tip: Patients admitted from Care Homes will often have a MAR (medication administration record) chart used by staff. Asking for a copy can assist you in establishing recent compliance with medication and also in checking you haven’t missed anything on your initial clerking! Care home staff can also give you a good idea of what the person is normally like and provide a good collateral history.
Residential Home
These schemes provide individuals with their own room in a live-in, home-style accommodation with staff on hand 24/7 to provide support. Some have carers in-house and others require patients to have their own external care agency to assist with personal care such a washing, dressing, toileting and medication. They also provide a variety of social activities, with many employing a dedicated activities manager to oversee these. Residential homes are often tailored towards certain individuals needs, for example, specialising in mental illness or elderly care.
Nursing Home
Nursing homes are very similar to residential homes with the added provision of having a qualified nurse on-site at all times. This allows residents to benefit from someone to oversee and monitor care plans, provide and administer treatment such as injections. This also allows for the care of patients with more complex needs. Like residential homes, nursing homes often provide a wide range of social activities and are also often targeted towards specific audiences such as neurological disorders or learning disabilities.
Dual-Registered Homes
These are care homes that provide both residential and nursing care. These are often larger homes with multiple floors that split residents. For example, the ground floor may be for residential care whilst the first floor is for nursing care. The benefit of these homes for individuals is that there is an opportunity for the same home to continue their care should their care needs change. This means less stress for the individual and makes things easier for the family. To move to increased care they still need all the same assessments and paperwork.
Family Home/Own Home with Care Package
Patients may be discharged to their own homes or a family home with a package of care. This package could be for a short length of time or for the foreseeable future. This is covered more in the article on Discharge Planning.
Community Hospital
Patients may also have the option of going to a community hospital for rehab or further treatment. Community hospitals can provide basic nursing care but most do not have doctors on-site and therefore patients need to be transferred back should any emergencies occur.
Funding
Care costs money, whether this is through a package of care, independent living or a care home.
NHS Continuing Health Care Funding
If the patient qualifies for NHS continuing healthcare funding, all their healthcare needs can be paid for in full by the NHS – it is NOT means-tested. There are however strict criteria to meet for this to apply which are explained more fully in our article on Discharge Planning. It is aimed at patients who need the care to address significant physical or mental health issues.
Personal Health Budgets
This can be used to give the individual more choice in providers, however, this cannot be used to pay for a care home. It usually cannot be used to top up to pay for more expensive care.
Means-Tested
If patients are not eligible for NHS continuing healthcare, social workers should direct them to their local authority, who will, in turn, assess them and may grant them a means-tested care budget.
Private Funding
There is the option of funding care costs privately. This can be very expensive however some patients may choose this option to have the care they desire.
Case Study
Case 1: An 83-year-old woman admitted with pneumonia now requires increased care on discharge
An 83-year-old woman is admitted with a community-acquired pneumonia. She previously lived alone in a bungalow and managed independently, although her daughter visited twice a week to help with shopping. She has a background of heart failure, osteoarthritis and mild cognitive impairment, but prior to admission she was able to wash, dress and prepare simple meals without assistance.
During her hospital stay, she becomes deconditioned and is now only able to mobilise short distances using a Zimmer frame with supervision. Occupational therapy reviews reveal that she struggles with lower-body dressing, needs prompting for personal care, and becomes confused when fatigued. Physiotherapy notes indicate that she is unsafe to manage stairs due to unsteadiness. The therapy team conclude she will require a package of care to return home safely, consisting of assistance with washing, dressing and meal preparation.
Her daughter expresses concern that her mother’s cognitive decline seems more noticeable. She worries she will not always be able to respond if her mother falls, and she asks whether a care home might be more appropriate. The patient, however, firmly states she wants to return to her own home. She acknowledges that she has been “a bit slower recently” but insists she can manage with “just a bit of help.”
The discharge coordinator becomes involved to explore available community options. They confirm that the patient’s local authority can provide up to four-times-daily (QDS) carers, but they emphasise that this level represents the upper limit before considering residential care. The patient would not meet criteria for NHS Continuing Healthcare, but she may be eligible for a means-tested social care package depending on her financial assessment.
A mental capacity assessment is completed to determine whether she has capacity to decide on her discharge destination. She is able to explain the risks of returning home, describe how carers could support her, identify what might happen if she refused help, and articulate clear reasons for wanting to remain in her own environment. She therefore demonstrates capacity to make this decision, even though her daughter feels a care home might be safer.
Given her expressed wishes and her capacity, the MDT agrees to facilitate discharge home with a QDS package of care, community physiotherapy follow-up and telecare equipment (an emergency call bell). The daughter is reassured that if her mother’s needs increase further, supported living or residential care options can be revisited. The discharge coordinator arranges the care package, confirms funding arrangements and ensures that the necessary equipment—such as grab rails and a shower chair—is delivered before discharge.
References
Written by Dr L Pennock (FY1)
Reviewed by Dr Corrinne Quah (Consultant Geriatrician)
Updated by Mr Amar Sidhu (CT2 in Trauma & Orthopaedics)
