By Kathryn McEwan, Northumbria University, UK
Sarah helped her father pack his belongings; relief mixed with rising anxiety. After five days in hospital following his stroke, he was being discharged. A nurse had briefly mentioned medication changes and follow-up appointments, but Sarah (who would be providing his care at home) hadn’t been part of those conversations. She left with a discharge summary she didn’t fully understand, unclear about warning signs to watch for, and no idea who to call if problems arose. Within 48 hours, her father was readmitted to hospital.
For many patients and caregivers, hospital discharge marks the start of an uncertain, unsupported transition, where responsibility for managing care needs shifts sharply to the home environment. When this handover fails, through rushed explanations, missing information, or lack of caregiver involvement, the consequences can be severe: preventable readmissions, deterioration at home, and overwhelming stress for those providing care.
The scale of the problem
The challenge is substantial. In England, approximately 13,000-14,000 patients per day remain in hospital despite being medically fit to leave (October 2025 data), with delayed discharge contributing to lost bed capacity, longer ambulance handover times, and cancelled procedures. One in seven hospital beds is occupied by someone no longer needing acute care, with similar pressures seen internationally.
Over half of unpaid caregivers (family members, friends, or neighbours providing support), report they were not involved in discharge decisions. These caregivers perform complex tasks including medication management, wound care, and equipment operation. Yet research shows many feel unprepared, receive inadequate guidance, and are overwhelmed by the complexity of tasks they are expected to manage after discharge.
What can be done better during hospital discharge?
Our recent co-produced research with caregivers, health and social care practitioners, and voluntary sector colleagues confirms these challenges while providing practical solutions. We identified that communication failures stem not from individual failings but from system-level pressures and structural barriers.
Three behaviourally informed strategies emerged as immediately actionable for healthcare professionals:
- Start discharge conversations at admission
Caregivers consistently described feeling brought in late, after key decisions had been made. This mirrors international research on transitional care showing that early caregiver involvement reduces cognitive load, prevents unrealistic expectations, and creates space to address anxieties before they compound. The COVID-19 pandemic disrupted these practices, dedicated ward-based social workers and family contact at admission were lost, affecting discharge planning today.
- Use plain, everyday language to manage expectations
Caregivers described struggling with jargon, acronyms, and rapid explanations. Some googled medical terms in real time, while emotional strain and unfamiliar environments hindered information absorption. This experience is well-documented: research on caregiver preparedness and health literacy identifies inadequate communication as a barrier to safe discharge. Systematic reviews show that caregivers often switch from being totally dependent on nurses in hospital to total self-reliance at home, overwhelmed by the complexity of tasks they are expected to perform.
Clear, concrete language reduces errors and builds trust. Practitioners told us they sometimes overestimate what caregivers can realistically manage at home. This aligns with research showing power imbalances between caregivers and professionals, healthcare staff’s greater familiarity with healthcare systems can unintentionally marginalise caregivers from important conversations. Being transparent about system pressures, care limitations, and what is genuinely achievable helps prevent misunderstandings and frustration later. This honest communication supports caregivers to plan effectively rather than facing unexpected demands.
- Provide one clear point of contact after discharge
Caregivers described profound uncertainty about who to call with medication queries, equipment delays, or signs of deterioration. This lack of clarity fuels anxiety and can lead to unnecessary readmissions or delayed help-seeking. Evidence shows that providing a single named contact, even if triaging queries onward, significantly reduces caregiver stress and improves safety. Research on continuity of care shows that ‘being known’ by services reduces fear and improves decision-making for patients and caregivers.
Putting these principles into practice
To support implementation, we co-produced a Caregiver Discharge Toolkit containing five flexible tools: a welcome letter, an admission guide, a “What Matters to You?” prompt card, a shared discharge checklist, and a post-discharge contact card. Designed for busy wards, these tools improve the relational aspects of discharge while accommodating diverse caregiving identities and can be adapted to hospital teams, community services, and voluntary sector organisations.
The message from caregivers and professionals
Small, intentional communication changes can transform discharge from a rushed endpoint into a supported transition. When caregivers feel recognised, informed, and prepared, when they’re treated as partners, outcomes improve for everyone.
Supporting caregivers isn’t just compassionate, it’s essential for safe, effective discharge. Our toolkit and the principles behind it offer a practical starting point for teams committed to making that shift.
Practical recommendations
- Start discharge planning at admission, not discharge.
Early involvement reduces anxiety, avoids unrealistic expectations, and creates time for education and problem-solving. Use simple questions to establish shared understanding from the outset:
Who supports you at home?
What already works well in your daily routine?
What might be difficult after discharge?
This reframes discharge from an abrupt handover to a gradual, supported transition, allowing time to co-ordinate post-discharge services and address concerns before they compound.
- Use plain, everyday language and check understanding
Avoid jargon. Replace “mobility issues” with “difficulty walking”, “observations” with “checking temperature and blood pressure”. After explaining medication change or care tasks, check understanding rather than assuming it. Use open prompts:
What would help you feel more confident once home?
What worries you most about managing at home?
These questions create space for misconceptions to surface. Be transparent about system pressure and what is genuinely achievable, this reduces frustration and supports realistic planning.
- Provide one clear post-discharge contact.
Make existing communication routes explicit and predictable. Provide a name, phone number, and guidance on when to call (e.g., “Contact Louise Jones, discharge nurse, for questions about medication or equipment between 9am-5pm weekdays”). Even if that person triages queries onward, knowing there’s someone to turn to transforms the post-discharge experience from abandonment to supported care.
