01
Begin planning before discharge
Ask what has changed, what the person can do independently and what help is expected at home. With consent, share relevant discharge information with the care provider so assessment and staffing can begin.
- Expected date and transport
- Mobility, transfers and equipment
- Medicines and responsibilities
- Meals, personal care and continence
- Follow-up appointments and warning signs
02
Choose the right support pattern
Some people need several visits each day; others benefit from a settling-in visit, short-term live-in care, waking-night support or a nurse-led package. Physiotherapy or occupational therapy may help with rehabilitation, equipment and daily activities after their own assessments.
03
Make responsibilities clear
The care plan should state what Care Circle will do, what remains with NHS or community teams, what family members have agreed and when to escalate concerns. Confirm equipment, access and medicines before care begins.
04
Review and adjust
Post-discharge care may be temporary. Reviews can reduce visits as independence improves or identify a need for ongoing help. The person’s goals and choices should guide decisions alongside current risks.