1. Introduction

The Hospital Discharge and Community Support Guidance (Department of Health and Social Care – DHSC) sets out how NHS bodies (including commissioning bodies, NHS trusts and NHS foundation trusts) and local authorities should plan and deliver hospital discharge and recovery services from acute and community hospital settings.

The discharge of adults from mental health hospitals and people at risk of or experiencing homelessness are covered by separate DHSC guidance: Discharge from Mental Health Inpatient Settings and Discharging People at Risk of or Experiencing Homelessness.

Hospital discharge is the final stage in an adult’s journey through hospital, following the completion of their acute medical care and move to an environment best suited to meet any ongoing health and care needs they may have. This can be:

• going home with little or no additional care (simple discharge);
• a short-term package of home-based; or
• bed-based care and recovery support in the community, while awaiting assessment of any longer-term care needs (complex discharge).

Adults should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way.

Whenever it is identified that a person may need support from social care services to aid their discharge and recovery, the NHS trust should inform the relevant local authority as early as possible in the person’s hospital stay.

Multidisciplinary discharge teams and care transfer hubs (see Section 5.1, Care transfer hubs and 5.3, Hospital discharge multidisciplinary teams), consisting of practitioners from all relevant services (such as health, social care, housing, the voluntary and community sector), should work together alongside the person being discharged and their carer or family, where relevant, to plan their discharge.

As far as possible, adults should be offered choice on what care and support they receive on discharge from hospital. They should be supported to make fully informed decisions, in conjunction with family / friends as appropriate (and where the adult consents), independent advocate / lasting powers of attorney (LPA) responsible for health and welfare, where they do not have the mental capacity to consent. The discharge process should be person-centred, strengths based and driven by choice, dignity and respect.

For specific organisational responsibilities related to discharge processes, see Annex C Hospital discharge and community support guidance (DHSC).

For information about decision making in acute settings, see Annex D: criteria to reside – maintaining good decision-making in acute settings Hospital discharge and community support guidance (DHSC).

2. Discharge Planning

Planning for discharge should begin when the adult is admitted to hospital. Where people are undergoing prearranged procedures, the planning should be discussed during at appointments before they are admitted, with plans reviewed before discharge. This will enable the person and their family / carers to ask questions and receive information to help make informed choices about the discharge pathway that best meets their needs (see Appendix 1: Discharge to Assess – Operational Process).

Where the adult already has a care and support plan in place, this should be used or updated as part of early discharge planning involving the person receiving care and others such as family / carers, the current care provider and voluntary and community sector services to ensure any change in their needs can be met. A Comprehensive Geriatric Assessment can also be used as a tool to support discharge planning for older adults with complex needs.

Planning of post-discharge (including long term needs assessments and end of life care, where appropriate) should involve multidisciplinary teams working across health and social care.  Social workers, including children’s social workers of young carers and young adult carers, should be involved where appropriate. Any mental capacity and safeguarding concerns should also be considered (see Mental Capacity and Adult Safeguarding chapters).

The Capacity Tracker and other data sources can be used to identify what local services are available. The tracker is a searchable database containing details of vacancies in Care Quality Commission (CQC) registered care homes, community rehabilitation, substance misuse and hospice locations.

Discharge planning for adults should also cover information about their post-discharge care and support, such as advice and information about voluntary and community sector organisations, housing options (such as home adaptations, the Disabled Facilities Grant (DFG) and possible alternative housing) and NHS and / or social care crisis response teams that can be contacted if needed.

2.1 Conversations before discharge

During discharge planning, people with new or additional needs may be offered choices of short-term health and / or social care and support in the community to aid their post-discharge recovery. The choices offered will depend on what is in place locally and is suitable for a person’s short-term recovery needs and available at the time of discharge.

People should be supported to participate actively in making informed choices about their care, including, for people who fund their own care, the potential longer-term financial impact of different care options after discharge (see Self-Funders chapter). These conversations should begin early as part of discharge planning and not wait until the person is ready to be discharged. This should include, where appropriate, information about housing options (including adaptation of the existing home and possible alternative housing, for example supported living).

Where there is disagreement between a person and their unpaid carers or family members, and the appropriate professional has no reason to consider that the person lacks mental capacity to make decisions relevant to their discharge, the matter will need to be resolved, hopefully through informal agreement. Where an adult wants to return home and their family member or unpaid carer is unwilling or unable to provide the care needed, NHS bodies, local authorities and care providers should work together to assess and provide the appropriate health and social care provision required to facilitate the adult ’s choice, where possible, and enable a safe discharge.

If a person does not accept a short-term package or temporary placement from the options offered, following discussion they should be discharged to an alternative that is appropriate for their short-term recovery needs. People do not have the legislative right to remain in a hospital bed if they no longer require care in that setting, including waiting for their preferred option to become available. Those on the D2A pathway should be discharged to a temporary care home placement for an assessment of long-term or ongoing needs, after which the decision about their permanent care home placement should be made.

3. Involving Family, Friends, Unpaid and Young Carers

Family members, friends and other unpaid carers play a vital role in the care of people who are discharged from acute and community settings.

From the outset, the adult should be asked who they wish to be involved in and / or informed of discussions and decisions about their discharge and asked to consent to share this information with them. This may include their family members (such as their next of kin), friends or neighbours. Paid care workers and personal assistants (PAs) should also be involved, to ensure that any changes that may be needed to an adult’s care and support plan can be put in place in a timely manner.

As early as possible in discharge planning – or as early as possible during a period of recovery – the status and views of any unpaid carers should be sought, including whether they are willing and able to continue to provide support and care after discharge. Young carers under the age of 18 should receive age-appropriate support.

3.1 Young carers

Where a young carer is identified, or any professionals responsible for care planning have concerns that the person will be discharged into the care of a person under the age of 18, the relevant local authority children’s social care should be notified so they can consider whether a young carer’s assessment is required.

Young carers assessments look at whether it is appropriate or excessive for the young carer to provide care for the person in question, in light of the young carer’s needs and wishes. When involving young carers in discharge planning, it is also important to consider whether there are any safeguarding issues for them, as well as for the person they are caring for. Any safeguarding concerns should be referred to the local authority (see also Young Carers, Lambeth Safeguarding Children’s Partnership procedures and Lambeth Safeguarding Adults Board procedures).

3.2 Carer’s Assessments

Following a hospital discharge, a person may need support from a carer for the first time or existing needs for care may increase. A carer’s assessment should be completed before any new caring responsibilities begin. If there are increased care needs, the previous carer’s assessment and support plan should be reviewed and updated (see Carers assessment, Assessment chapter and Care and Support Planning chapter). If the carer’s assessment needs to take place before discharge, it should be organised in a timely manner so as not to delay discharge from hospital. If an unpaid carer has substantial difficulty engaging in the assessment, they should be referred for independent advocacy support (see Independent Advocacy chapter). Young carers in particular may benefit from independent advocacy support.

Not everyone who is (or will be) providing ongoing care will identify as an ‘unpaid carer’. However if a person is acting in the role of an unpaid carer, they should be regarded as one and involved in key discussions about the care needs of the adult after their discharge from hospital, or in having their own needs assessed. In other cases, the person being discharged may themselves have caring duties, for example being a parent of a disabled child. A person who does not have family or friends to help, or who may find it difficult to understand, communicate or speak up, should be informed of their right to an independent advocate (see also Independent Advocacy chapter). Any LPAs should also be identified and consulted when appropriate.

Where there are concerns that relationships may be abusive – the adult or their unpaid carer may be abused, may be abusive or neglectful, – local safeguarding procedures should be followed (see Domestic Abuse and Adult Safeguarding chapters).

4. Discharge to Assess

Under the Discharge to Assess Model and Home First Approach to hospital discharge, most people are expected to go home (that is, to their usual place of residence) following discharge. The discharge to assess model (D2A) is based on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed.

D2A involves providing short-term care, rehabilitation and reablement, where needed, and then assessing people’s longer-term needs for care and support once they have reached a point of best recovery. This may be in people’s homes or using ‘step-down’ beds to support the transition from hospital to home. D2A means that people do not wait unnecessarily in hospital where there is a higher risk of acquiring infections or deconditioning. Assessing people’s needs out of hospital in the most appropriate setting and at the right time for them, supports independence and long-term outcomes.

In ‘cross border’ situations where a person might be placed for short-term care in a community bed-based setting that is outside of their ‘home’ local authority area, responsibility for funding should be determined in accordance with the Who Pays? Rules for services that are for the NHS to fund, and with reference to ‘ordinary residence’ rules for services that are funded by local authorities (see Ordinary Residence and Continuity of Care chapters).

People may be entitled to support from an independent advocate if they do not have a friend or family member to support them during the discharge process (see Independent Advocacy chapter).

People should not be routinely discharged to a community step-down bed simply to free up a hospital bed, nor should they routinely be discharged to a community bed simply because home-based care is not available. Where this does happen, it should be a short-term solution and reviewed quickly following discharge.

5. Providing the Right Support

Health and care professionals should work together with adults, and – where relevant – their families / carers to discharge people to the setting that best meets their needs. For more most people, this will be their own home. The discharge process should be person-centred, strengths-based and driven by choice, dignity and respect.

Most discharges should be simple, as the adult can go home without arranging additional onward care or support. Even so, it is important that non-clinical factors are considered, and any unpaid carer is involved, to ensure safe and effective discharges. Where people have more complex care and support needs, most can go home with short-term recovery support in place, although some adults will need short-term bed-based care to aid recovery.

Only in exceptional circumstances should someone be considered to need long-term care at the point of discharge from hospital, and even then, under D2A, other than in exceptional circumstances, they should be discharged to a temporary placement for assessment of their long-term or ongoing needs beyond discharge (see Appendix 1: Discharge to Assess -Operational Process).

People should be discharged to a familiar setting whenever possible, as they often respond well to the familiarity of their home environment. If required, people should receive recovery support in the community, such as home or bed-based intermediate care (including short-term rehabilitation, reablement and recovery) to enable them to regain their independence as far as possible. This can lead to a more accurate assessment of their future needs once they have reached an improved point of recovery.

Practitioners should consider a range of factors when supporting the adult and their family / carers to decide their care pathway and post-discharge care and support, including:

• the adult’s preferences;
• existing provision of care; and
• whether family / carers are willing and able to support the adult’s recovery.

Discharging people to the most appropriate place to meet their needs requires active risk management across organisations, and there needs to be a reasonable balance between safety at all times and independence. Where a person has the mental capacity to make a decision about what care and support they would like on discharge, they should be supported to manage any risks.

Even where a professional (including medical and social care professionals) disagrees with a person’s choice, in most cases, if they have mental capacity to decide what care and support they would like on discharge they will make the final decision. If an adult with mental capacity refuses the provision of care, then ultimately this decision should be respected (see Mental Capacity chapter).

It is best practice for a person’s immediate recovery care and support needs to be decided before discharge, and a plan put in place on how to meet them. Anyone requiring formal care and support to help them recover after discharge, should receive an initial safety and welfare check on the day of discharge to ensure safety and care needs are met. The care transfer hub should coordinate the initial check. Fuller assessments should take place as the person settles in their environment. It is not appropriate for people to make decisions about long-term care while they are in crisis or in an acute hospital bed.

People with ongoing mental health needs, a drug or alcohol dependence, a learning disability, dementia, those in the last few months of life, and other needs or conditions may require specialised support in the community. This may include an allocated social worker or social care professional and / or support from community mental health or drug and alcohol services, to ensure their needs continue to be met. Anyone facing the loss of a loved one should be given information on specialist bereavement support.

5.1 Care transfer hubs

Care transfer hubs (or other co-ordination hub or single point of access) are made up (physically and / or virtually) of multidisciplinary teams (such as health, social care, housing and the voluntary and community sector). They work in an integrated way to provide clinical, professional decision-making to support the planning of complex discharges, and to broker the required support through adult social care, intermediate and community health services.

5.2 Case management approach

A case management approach should be used for all adults being discharged through the care transfer hub to support their discharge and recovery. Each adult should be clearly assigned to a member of staff in the care transfer hub at any one point, even if that staff member changes over time, for example because of working patterns.

A case manager will arrange for an adult to have an initial holistic safety and welfare check on the day of discharge to ensure their safety and that care needs are met. Fuller assessments should take place as the person settles. A case manager will also monitor and support progress against agreed goals in the adult ’s care and support plan, ensuring adjustments are made or the support stopped if necessary.

5.3 Hospital discharge multidisciplinary teams

Hospital discharge multidisciplinary teams will identify- with input from the person and their family / carer and relevant community-based professionals – needs that will require support after discharge but before an assessment of long-term needs has taken place. These include non-clinical factors such as physical, social, psychological, cognitive, financial and practical needs, and any need for home adaptations and equipment. This could determine whether the person’s home is suitable for their needs upon discharge.

Multidisciplinary teams can include social workers, clinicians, therapists, mental health practitioners, pharmacists, care workers, dietitians, housing representatives, voluntary and community sector services and any other specialists needed to coordinate care for the adult. They use strengths-based and person-centred planning, to plan care and support and carry out joint assessments.

If a person requires short-term care in a residential setting, staff working in the hospital discharge multidisciplinary teams will identify suitable vacancies.

5.4 Hospital-based social workers

As members of a discharge multidisciplinary team, hospital-based social workers ensure a person-centred and strengths-based approach is adopted during pre-admission, hospital stays and planned safe discharge. Their role in hospital and assessment settings is essential for people whose social circumstances are complex. These social workers support people to make informed choices, weighing up the risks and benefits of options, and taking into account mental health, mental capacity and safeguarding issues and carers’ rights.

5.5 GP surgeries

General practice and other primary care providers, as well as social care and community providers, have an important role in discharge planning to ensure that health recovery support is available to the adult throughout their care journey.

5.6 Ensuring discharge is timely and safe

Health and social care professionals should support and involve the patient to be discharged in a safe and timely way. People should be discharged once they no longer need care in that setting. Timely discharge from acute settings improves a person’s outcomes and reduces the risk of medical complications and loss of independence.

No person should be discharged until it is safe to do so. This should include ensuring that, where relevant, unpaid carers have been consulted on whether they are willing and able to provide care and support after the adult has been discharged. Young carers should be offered independent advocacy support if they want it, to support them to consider how they will be impacted.

5.7 Assessing for long-term needs

Intermediate care may be provided to a person in their own home or a community bed-based setting to support their recovery following discharge. This can include rehabilitation, reablement and recovery support from NHS or social care services tailored to their needs.

It is best practice to discuss immediate recovery needs with the person and put in place a plan on how these will be met before they are discharged. It is also best practice to start assessments of their longer-term health and / or social care and support needs during the period of recovery and complete them only when the adult has reached a point of recovery and stability.

If longer term care, treatment or support is needed, the adult should be fully involved in considering what form that might take and in weighing up the risks and benefits of the options that are available. This includes, if they require, consultation with family / carers who are willing and able to provide care and support. A health and welfare LPA can only be used when the donor has lost the mental capacity to make the relevant decision for themselves. If the adult does not have any friends or family, then an independent advocate should be consulted if the adult agrees (see Independent Advocacy chapter).

For those with the highest levels of complex, intense or unpredictable needs, screening and assessment of eligibility for NHS continuing healthcare (CHC) should take place when the adult ’s ongoing needs are clearer to enable an appropriate health and social care package to be provided (see Continuing Healthcare chapter). The CHC assessment should normally take place when the adult is in a community setting. There may be rare circumstances where the CHC assessment may take place in an acute hospital environment. The core principle is that adult should be supported to access and follow the process that is most suitable for their current and ongoing needs.

In the case of palliative and end of life care, assessments should take place when the person is as stable as they are likely to become, when their long-term care needs will be clearer. People with palliative and end of life needs, particularly those who may die within days or weeks, will require particular support (see Section 6.1 Palliative and end of life care).

5.8 Risk management

Multidisciplinary teams should work together to coordinate discharges of adults with complex care and support needs. Any risks should be managed carefully with the adult and their family / carer, as there can be negative consequences from decisions that are either too risk averse, or do not sufficiently identify the level of risk. For example, people may be discharged onto pathways which result in levels of care that they do not need, or adults may not receive the care and support they need to recover.

Any onward care providers should be included early in the person’s discharge planning process. This allows more time for local capacity to be managed and suitable support to be put in place. People’s care needs may also change, and there should be processes in place to ensure these needs are continuously reviewed and that the person is receiving appropriate support.

Where a person has mental capacity to make a decision about their care and support at the point of discharge, health and social care professionals should support them to manage their own risk. Principle 3 of the Mental Capacity Act 2005 provides that a person cannot be treated as lacking capacity merely on the basis that they have made an unwise decision (see Mental Capacity chapter).

A lead professional / single point of contact should be identified to support integrated working across health, housing, social care and other key organisations, and to ensure that the adult or the family can easily communicate with professionals. The adult should be given the contact details of someone who they can talk to about their discharge and advised to make contact if they are concerned about anything.

It is not appropriate for people to be asked to see their GP or go to the emergency department following discharge for issues with their social care. Where appropriate, information provided to the person on discharge should be shared with anyone providing care for the person.

6. Specific Needs

6.1 Palliative and end of life care

See also End of Life Care chapter

Adults requiring palliative and end of life care and support should have their palliative and end of life needs anticipated and planned as part of their discharge process. To address this, each adult should be offered a personalised care and support plan, which may include an advance care plan (see Advance Care Planning chapter). Hospital discharge is an important opportunity to help them review and update their advance care plan if they wish to, or to initiate advance care planning conversations. Such conversations must be ongoing with their options regularly reviewed, revisited and revised beyond discharge.

Health and care providers (including hospices) should work together to minimise common issues that can disrupt the provision of care as part of the discharge process. This includes:

• anticipatory prescribing;
• access to medication and trained professionals to administer them where necessary;
• appropriate equipment (such as a hospital bed);
• 24-hour nursing care;
• allied health professionals (such as occupational therapy).

Health and care professionals should support applications for benefit payments for those who are eligible (there are ‘special rules’ for end of life).

The needs of unpaid carers should also be considered.

Following discharge, people receiving palliative or end of life care should be given appropriate and compassionate support to enable them to continue living as well as possible.

Effective and timely discharge is particularly important for people who have been recognised by their clinician as having a primary health need arising from a rapidly deteriorating condition and who may die within days or weeks. This should be possible whenever necessary, including out of hours.

6.2 Sharing information

See also Information Sharing and Confidentiality chapter

Relevant care and support information should be shared in a timely way with the adult and the people and services who will provide onward care support, such as intermediate care services, domiciliary care teams, community health services, care homes, GPs, unpaid carers, independent advocates and family members.

Health and care professionals (such as clinicians and social workers) should share appropriate and accurate information early to support a safe and timely discharge, for example, about medication (including whether medication has changed since hospital admission) and immediate support needs, including transport and equipment required.

Sufficient and accurate information should be provided on discharge to enable any providers of onward care and support to meet the needs of the person transferred to them. This includes details about the person’s condition, information about their medications, whether a care and support plan has been updated or established, and arrangements to have their care and support regularly reviewed to support their recovery.

Health and care professionals should share key information about an adult’s communication needs (for example, if they have a learning disability or dementia), specific care preferences and details of any unpaid carers and family members. Practitioners should make ensure that any unpaid carer is identified on the person’s health and care record. If an adult experiences substantial difficulty in communicating their needs and does not have a friend or family member to support them, an independent advocate must be instructed (see Independent Advocacy chapter).

6.3 Mental capacity, advocacy and special arrangements for discharge

Some people with advanced dementia, autism, learning disabilities and acquired brain injury, among other groups, will be assessed to ‘lack the mental capacity’ to make specific decisions about their own lives (see Mental Capacity chapter).

Mental capacity is decision-specific and time-specific, and assessments should not be about their ability to make decisions generally. If there is a reason to believe a person may lack the mental capacity to make relevant decisions about their discharge arrangements at the time the decisions need to be made, a mental capacity assessment should be carried out as part of the discharge planning process. Where the person is assessed to lack the mental capacity to make a relevant decision about discharge, any best interests decision must be made in line with the Mental Capacity Act.

No one who lacks the relevant capacity should be discharged to somewhere assessed to be unsafe, and the decision maker who makes the best interests decision should make a record of the decision.

Mental capacity assessments and best interests decisions must consider the available options. Onward care and support options which are not suitable or available at the time of hospital discharge cannot be considered in either mental capacity assessments or best interests decision-making.

In certain circumstances during discharge planning, health and care providers might determine that someone is, or will be, deprived of their liberty because of the proposed arrangements for their care and treatment. In these circumstances, decision makers must comply with the legal requirements regarding the person’s right to liberty. For adults residing in a care home or hospital, this would usually be provided by the deprivation of liberty safeguards (DoLS) (see Deprivation of Liberty Safeguards chapter). This includes carrying out a mental capacity assessment and a best interests assessment before a decision about discharge to a care home is made, if there is reason to believe a person may lack the mental capacity to consent to their discharge arrangements which amount to a deprivation of their liberty.

In some cases, it may be appropriate for an independent advocate to support an adult during the discharge planning process, and this may be a legal requirement. Referrals to independent advocacy services should be made as soon as discharge planning begins and ideally upon admission, or where there is a legal duty to provide an independent mental capacity advocate (IMCA) as soon as the legal criteria applies (see Independent Advocacy and Independent Mental Capacity Advocate Service chapters).

If there is a deputy or attorney with authority to make relevant decisions about discharge, then they will be the best interests decision maker for the purposes of the MCA.

6.5 Tailored support

Where there are ongoing health, housing or social care needs after discharge with different care options available, adults (and, where relevant, their family / carers / advocate) should be empowered and supported to make the best choice for their individual circumstances.

To reduce health disparities and inequalities, health and social care professionals should consider the needs of groups that might need specialised support on discharge. This requires an understanding of issues relevant to people from black, Asian and minority ethnic groups, people who identify as LGBTQI, faith or cultural needs, people living with disabilities, autistic people, older people, unpaid carers, people who do not speak English, and those with specific communication needs (see Providing Culturally Appropriate Care chapter).

For people where new mental health concerns have arisen, case managers should contact psychiatric liaison teams to review and assess as appropriate. For people with pre-existing mental health concerns, a care coordinator or relevant mental health clinician should be involved in the discharge planning to ensure their mental health needs are considered. They should ensure that the proposed onward care provider, if relevant, is fully aware of the person’s support needs.

For those who are being discharged from acute or community settings following an episode of self-harm, the provider should consult NICE guidelines to ensure appropriate processes are being followed (see Transition between inpatient hospital settings and community or care home settings for adults with social care needs). Where an adult presents with mental distress but does not meet the criteria for secondary mental health services, a preventative mental health offer should be available, for example signposting to services such as a provider of local NHS talking therapies.

NHS trusts should identify, at the point of admission, anyone who is experiencing homelessness or threatened with homelessness. They should refer the person to the local authority homelessness or housing options teams as early as possible during their stay, under the requirements of the Homelessness Reduction Act 2017, if the person consents (see Homelessness chapter).

People who are experiencing homelessness or at risk of homelessness should not be excluded from short-term post-discharge recovery and support because of their housing status.

For people living in poor or unsuitable housing, the local housing authority has a duty to provide any necessary adaptations (as determined by legislation and regulations underpinning the Disabled Facilities Grant System) and assess housing needs.

Many people admitted to acute medical units have a condition which makes them frail (see Working with People Living with Frailty chapter), where people suffer multiple physical, cognitive and functional impairments. This can result in longer stays in hospital and higher rates of hospital-acquired harms such as falls, infections, delirium and adverse drug events. Research suggests that the average readmission rates within 30 days are around 20% in this group, but many can be prevented by comprehensive assessment and discharge planning that includes a specific focus on:

• medicines reconciliation and optimisation;
• patient and carer information, advice and support;
• falls interventions;
• provision of assistive technology to mitigate risk at home.

The usual pathway for people with frailty is discharge home first, with recovery support at home to help them regain functional ability after discharge. However, some people with more severe frailty may require a period of step-down bed-based care to support them to recover and / or regain their confidence, maximising independence and delaying progression to long-term residential care.

7. Further Reading

Discharge from Mental Health Inpatient Settings (Department of Health and Social Care) 

Discharging People at Risk of or Experiencing Homelessness (Department of Health and Social Care) 

Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NICE)

Quick guide: discharge to assess (NHS England and ADASS)

Managing transfers of care – A High Impact Change Model (LGA)

Why not home? Why not today?’ reducing length of stay action cards (NHS England)

Effective commissioning for a home first approach (NHS England)

Top tips guidance on implementing a home first approach to discharge from hospital (LGA / ADASS)

Top tips guidance on implementing a collaborative commissioning approach to home first (LGA / ADASS)

Appendix 1: Discharge to Assess – Operational Process

1. Admission for planned treatment: Where somebody is admitted to hospital for planned treatment, their likely short-term care needs upon discharge should be considered and discussed with them before they are admitted. A provisional plan should be put in place at this point, including what support will be available from family and friends, so that they are able to prepare for the discharge prior to admission.
2. Admission as an emergency: Where somebody has been admitted to hospital as an emergency admission, their likely short-term care needs on discharge should be considered as soon as possible after their admission. It is good practice to set an estimated date of discharge and destination (type of setting) within 48 hours of admission. This should be discussed with and communicated to the adult, their family / carer and care home (if that is their normal place of residence).
3. Providing an interim package of care: Where a patient is likely to need an interim package of care on leaving hospital, pending any assessment of their longer-term care needs, the relevant care transfer hub should ensure that a multidisciplinary team assesses the appropriate discharge pathway (type of setting) and any immediate support the person will need on being discharged, including any issues relating to safeguarding and housing. This will include confirming any immediate home-based support required, for instance support from voluntary and community sector organisations to make their home suitable for discharge and / or social care packages of support, or any specific risk issues and support needs if being discharged to a bedded setting.

The assessment should be reviewed as the patient continues to recover while in hospital, keeping the best interests and outcomes for the adult at the centre of decision-making. Post-discharge needs should be discussed with adults, their family / carers. All practical assistance should be made available to encourage and support the person to make decisions for themselves.

Before an adult is discharged, the multidisciplinary team and care transfer hub should confirm the discharge pathway and a prescription for the immediate support needed. The care transfer hub should make final arrangements to ensure a smooth and timely transfer of care.

Hospitals should consider the adult’s recovery and support needs from the point they are admitted or, in the case of elective patients, prior to admission, and take appropriate steps to prevent avoidable deconditioning while they are in hospital. Where patients need short-term therapy-led rehabilitation, reablement and / or recovery support following discharge, these needs should be identified as soon as possible in hospital.

Depending on the adult’s circumstances, it may be appropriate – and may support timely discharge – to make final decisions on the precise nature of any post-discharge support and arrange that support shortly after they have left hospital. Where this is the case, the decision about where to discharge the patient to, should take account of which provider is best placed to meet their rehabilitation, reablement and / or recovery needs.

Assessment of longer-term needs

Assessments of longer-term care needs (including Care Act assessments) should take place after someone has left hospital and after an initial period of recovery. In the case of continuing healthcare assessments, it is best practice to screen at the right time and in the right place for that adult (see Continuing Healthcare chapter). In most cases this will be following discharge and after a period of recovery.

Appendix 2: Discharge pathways

Pathway 0

Simple discharge home (to usual place of residence or temporary accommodation) coordinated by the ward without involvement of the care transfer hub, with:

• no new or additional health and/or social care and support;
• self-management with signposting to services in the community;
• voluntary sector support;
• re-start of pre-existing home care package at the same level that remained active and on pause during the person’s hospital stay;
• returning to original care home placement with care at the same level as prior to the person’s hospital stay.

Pathway 1

Discharge home (to usual place of residence or temporary accommodation) with health and/or social care and support coordinated by the care transfer hub, including:

• home-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery at home;
• re-start of home care package at the same level as a pre-existing package that lapsed;
• returning to original care home placement with time-limited, short-term intermediate care;
• long-term care and support at home following a period of intermediate care in the community.

Pathway 2

Discharge coordinated through the care transfer hub to a community bedded setting with dedicated health and / or social care and support, including bed-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery in a community bedded setting (bed in care home, community hospital or other bed-based rehabilitation facility).

Pathway 3

In rare circumstances, for those with the highest level of complex needs, discharge to a care home placement coordinated through the care transfer hub, including:

• care home placement for assessment of long-term or ongoing needs and facilitation of patient choice in relation to the permanent placement;
• long-term care and support in a care home following a period of intermediate care in the community.