After Hospital Care in Exeter

After hospital care in Exeter, and the gap it fills

Most people leave the Royal Devon and Exeter at Wonford with a discharge letter, a bag of medication and a lift home. What they often do not have is anyone to make sure the next two weeks go well. The ward has done its job. The GP will see them at some point. In between, there is a house that has been empty, a fridge with nothing in it, a set of instructions nobody quite followed, and a person who is more tired and less steady than they were before they went in.

That gap is what I fill. Not nursing, which is what the NHS community teams are for, but the everyday things that decide whether someone recovers at home or ends up back on the ward. Food. Fluids. Medication taken as written. Getting washed safely. Getting to the appointment. Somebody noticing when something is not right.

Before the discharge date

The best after hospital care starts while the person is still on the ward. If you ring me as soon as a discharge is mentioned, I can come to the house beforehand. I will look at where they will be sleeping, whether the bathroom is manageable, what needs moving and what needs buying. We agree the pattern of visits for the first week and write it down. When the transport pulls up, the heating is on, there is milk in the fridge, and there is somebody there who knows the plan.

If the hospital has arranged a reablement team or district nurse visits, tell me and I will work around them. Everyone doing their own part, nobody duplicating and nobody assuming somebody else has done it.

The first two weeks

The first fortnight usually needs the most help, and it is where the pattern is heaviest. A morning visit to help with getting up, washed and dressed, especially the first few showers, which people are often nervous about after an operation or a fall. Breakfast, and the morning medication, checked against the discharge letter and recorded. A midday or afternoon visit for a proper meal, a short walk if that is what the physiotherapist wants, and a look at how the day is going.

Throughout, I am watching for the things that send people back to hospital. Not drinking enough. Not eating. New confusion. A wound that looks different from yesterday. Pain that is not controlled. When I see any of them I tell whoever you have asked me to keep informed and, if it is urgent, the GP or 111. Catching these early is most of the value.

Appointments, prescriptions and the pharmacy

Discharge usually comes with a list. A follow-up at the outpatients department. A GP review in a week. A blood test. A prescription that runs out on Thursday. I can collect prescriptions, drive to appointments and wait, and make sure the questions that were written on the back of an envelope get asked. For someone who cannot yet manage the car park at Wonford or the walk from the bus, that is often the difference between an appointment kept and one missed.

Tapering off

After hospital care is meant to end. As the person gets stronger, the visits get fewer. How long the arrangement runs is agreed at the first visit and written down. Either of us can end it with two weeks notice. Some families may find a couple of visits a week worth keeping on. Others will simply not need me any more. Both are the right outcome.

What this is not

I am not a nurse and I do not provide clinical care. Wound dressings, injections, catheter care and physiotherapy come from the NHS community services, and I make sure their visits happen rather than replacing them. I do not offer overnight care, so if somebody needs someone in the house through the night in the first days home, that is something family need to cover or a different service needs to provide. I say this at the first phone call so nobody is surprised.