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The focus should be on enabling people to access what they need through a tailored range of services that assists people to navigate all points and aspects of their journey through care and...
- About This Guidance
- Introduction
- The Care Journey
- Structure, Roles and Responsibilities
- Specific Needs
- Glossary of Terminology
- Related Guidance and Useful Links
- Annex A: Discharge to Assess - Operational Process
- Annex B: Discharge Pathways
- Annex C: Specific Responsibilities Related to Discharge Processes
This is statutory guidance intended for NHS bodies, including NHS England, English special health authorities, NHS trusts, NHS foundation trusts and integrated care boards (ICBs), as well as local authorities and integrated care partnerships (ICPs) in England. For the purposes of this guidance, the term ‘NHS bodies’ does not include Welsh NHS bodie...
Hospital discharge is the final stage in an individual’s journey through hospital following the completion of their acute medical care, when they leave an acute setting and move to an environment best suited to meet any ongoing health and care needs they may have. This can range from going home with little or no additional care (simple discharge), ...
1. NHS bodies and local authorities should agree the discharge models that best meet local needs and are effective and affordable within the budgets available to NHS commissioners and local authori...
NHS bodies and local authorities should adopt discharge processes that, in their judgement, best meet the needs of the local population and, where possible, take account of choice and preferences. This includes the discharge to assess model and home first approach. Funding to support discharge can be pooled across health and social care through an agreement under section 75 of the NHS Act 2006 to minimise delays. This can facilitate effective use of available resources and ensure the decision...
2. NHS bodies and local authorities should ensure that, where appropriate, unpaid carers and family members are involved in discharge decisions
Family members, friends and other unpaid carers play a vital role in the care of people who are discharged from acute and community settings. NHS bodies and local authorities should address local barriers to identifying and supporting unpaid carers throughout the discharge process. This includes ensuring local authorities continue to adhere to their duties in existing legislation, for example, those outlined in the Care Act 2014 and the Children Act 1989. From the outset people should be aske...
3. Planning for discharge should start on admission, or before for elective procedures
Planning for discharge should begin on admission. Where people are undergoing elective procedures, this planning should start pre-admission, with plans reviewed before discharge. This will enable the person and their family members or unpaid carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs. Further detail on the 4 discharge to assess pathways is set out in Annex B, below. Where there...
5. Local areas should develop a discharge infrastructure that supports safe and timely discharge to the right place and with the right treatment, care and support for individuals
Local areas should develop and implement the discharge model that best meets the needs of their local population and is affordable within the budgets available to NHS commissioners and local authorities. Discharging an individual onto the right care pathway when they no longer need to remain in acute or community care requires a whole system approach. NHS bodies have a duty to co-operate with local authorities, and they should work closely with adult and children’s social workers, care provid...
6. Joint accountability across health and social care leads to better outcomes
Health and social care practitioners, working in a co-ordinated and integrated way, have the ability to support safe and effective hospital discharge. Integral to this is: 1. person-centred care 2. multidisciplinary teams facilitating discharge planning, for example through a care transfer hub, which takes place from admission 3. collaborative and partnership working 4. flow of information across organisational and professional boundaries In its 2018 report, Beyond barriers: how older people...
7. Health and local authority social care partners should support people to be discharged in a timely and safe way as soon as they no longer require care in NHS acute hospitals, NHS community hospi...
Health and social care professionals should support and involve the patient to be discharged in a safe and timely way to ensure they do not spend longer than necessary in an acute or community hospital, or local authority run community setting. 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 such as deep-vein thrombosis, hospital acquired infections and lo...
10. Palliative and end of life care needs should be anticipated and met as part of an individual’s discharge journey
Individuals requiring palliative and end of life care and support should have their palliative and end of life needs anticipated and planned as part of the discharge process. To address this, each individual should be offered a personalised care and support plan, which may include an advance care plan. A hospital discharge is an important opportunity to help the individual review and update their advance care plan if they wish to, or to initiate advance care planning conversations. Such conve...
11. Information should be shared across relevant health and care teams and organisations across the system in a secure and timely way to support best outcomes
One of the purposes of integrating health and social care is to ensure smoother care pathways with care joined up around a person’s life, needs and wishes, including an individual’s information and data being shared between relevant organisations with their consent. Relevant care information should be discussed and communicated in a timely manner to the individual and the people and services who will provide onward care support, such as intermediate care services, domiciliary care teams, comm...
12. Planning and implementation of discharge should respect an individual’s choices and provide them with the maximum choice and control possible from suitable and available options
The NHS Act 2006 sets out the general duty as to patient choice on NHS England. These include a requirement on relevant bodies to ‘act with a view to enabling patients to make choices’. During discharge planning conversations 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 has been put in place locally and should be suitable for a person...
Care transfer hub
A physical and/or virtual co-ordination hub or single point of access whereby all relevant services across sectors (such as health, social care, housing and the voluntary and community sector) are linked together to co-ordinate health and/or social care and support to aid timely and person-centred discharge and recovery.
Case manager
A health and/or social care professional assigned to a person being discharged through the care transfer hub to support the person’s discharge and recovery.
Criteria-led discharge
A process by which clear clinical criteria for safe discharge are documented for selected patients that can be enacted by an appropriate junior doctor, nurse or allied health professional without further consultant review. Not all patients awaiting discharge will be suitable for criteria-led discharge, with most patients suitable fitting into discharge pathways 0 or 1.
This guidance should be read alongside the 2015 NICE guidance Transition between inpatient hospital settings and community or care home settings for adults with social care needs. Other relevant documents include: 1. Quick guide: discharge to assess (PDF, 862KB) - NHS England and ADASS 2. CQCguidance on trusted assessors (PDF, 185KB) 3. ADASSsnap s...
Where somebody is admitted to hospital for elective treatment their likely short-term care needs upon discharge should be considered and discussed with them prior to their admission. 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 dis...
Pathway 0
Simple discharge home (to usual place of residence or temporary accommodation) co-ordinated by the ward without involvement of the care transfer hub, with: 1. no new or additional health and/or social care and support 2. self-management with signposting to services in the community 3. voluntary sector support 4. re-start of pre-existing home care package at the same level that remained active and on pause during the person’s hospital stay 5. returning to original care home placement with care...
Pathway 1
Discharge home (to usual place of residence or temporary accommodation) with health and/or social care and support co-ordinated by the care transfer hub, including: 1. home-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery at home 2. re-start of home care package at the same level as a pre-existing package that lapsed 3. returning to original care home placement with time-limited, short-term intermediate care 4. long-term care and support...
Pathway 2
Discharge co-ordinated 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).
The following sections summarise specific responsibilities and best practice for NHS bodies, local authorities and care providers to follow when planning and delivering discharge services.
You may be eligible for free care and support at home for up to 6 weeks after a stay in hospital or to prevent you going into hospital. It's known as intermediate care or reablement. The idea is to get you back to being as independent as you were before.
Jan 26, 2024 · The Health and Care Act 2022 revoked Schedule 3 to the Care Act 2014, which required long-term health and care needs assessments to take place before discharge from hospital.
Jun 6, 2024 · As the Journey of Hope routes are making their way across the country, team members may need that little extra push from you in the form of a care package to get them through some hard miles between now and Washington, D.C. Below, you will find the mail drops for the Journey of Hope teams.
Packages of care A social worker will work with you, your family and friends to determine if a care package is required. They will work with you to determine what you can do for yourself, what you can do together and what care providers can do. A full assessment of your needs will identify what is required, how often and when.
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Apr 8, 2024 · Find out how to get the most from your medicines, including how to get the most out of your pharmacy. NHS continuing healthcare is a free package of care for people who have significant ongoing healthcare needs. It is arranged and funded by the NHS.
