Transfers and Discharges


Transition between inpatient hospital settings and community or care home settings for adults with social care needs, NICE, 2015

This chapter summarises the main principles and practice guidance points in the NICE publication, including issues of communication, as linked below.

1. Overarching Principles of Care and Support

1.1 Person centred care

Everyone receiving care and support is an individual and an equal partner who can make choices about their own care. They should be treated with dignity and respect throughout their transition to hospital settings.

The service should identify and support people at risk of less favourable treatment or with less access to services for example, people with communication difficulties or complex needs. Support may include help to access advocacy (see Independent Advocacy).

The service should involve families in discussions about the hospital care and treatment being given or proposed if the adult gives their consent. If there is doubt about the adult’s capacity to consent, the principles of the Mental Capacity Act 2005 must be followed (see Mental Capacity).

1.2 Communication and information sharing

The service should ensure that the adult, and all health and social care practitioners involved in someone’s move between home and hospital are in regular contact with each other. This is to ensure the transition is coordinated and all arrangements are in place. Staff at the service must give hospital staff information about the adult’s diagnoses and treatment and a complete list of their medicines when they transfer between home (supported living or care home) and hospital.

The service should be able to provide information to the adult and their family in a range of formats, for example:

  • verbally and in written format (in plain English); and
  • in other formats that are easy for the adult to understand such as braille, easy read or translated material.

2. Before Admission to Hospital

The service manager is responsible for ensuring the adult’s care and support plan contains all relevant information for adults who are at risk of being admitted to hospital at short notice or who have been notified of a planned hospital admission. This will include contingency planning for all aspects of the adult’s life. If they are admitted to hospital, staff should refer to this plan.

The manager or designated responsible person will give the hospital based multi-disciplinary team their name and contact details.

Wherever possible, the manager of the service or a designated responsible person will explain to the adult what type of hospital care and treatment they might receive. Discussions might include:

  • the place of hospital care and treatment;
  • respecting their religion, culture and spirituality;
  • daily routines (including the use of medicines and equipment);
  • managing risk;
  • how, when and where they receive information and advice;
  • if required, the use of a named member of staff or an advocate to support them when communicating their needs and preferences;
  • advance care plans;
  • contingency planning;
  • end of life care, where applicable.

3. Admission to Hospital

3.1 Communication and information sharing

The service should use communication protocols and procedures to support all admissions to hospital.

The manager or designated responsible person will ensure that the hospital admitting team is given all available relevant information. This may include:

  • behavioural issues (triggers to certain behaviours);
  • care plans;
  • mental capacity assessments
  • DoLS authorisations
  • communication needs;
  • communication passport;
  • current medicines;
  • hospital passport;
  • housing status;
  • named carers and next of kin and contact details;
  • named key worker and contact details;
  • other profiles containing important information about the adult’s needs and wishes;
  • preferred places of care
  • advance treatment plans.

In the event of an emergency admission, the service manager or designated responsible person must ensure that the Accident and Emergency Department is given all relevant information so this can be given to the admitting team when a adult is transferred for an inpatient assessment or to an admissions ward.

On admission to hospital and, following an appropriate review of all available relevant records and care plan information with the hospital admissions team, the service manager or designated responsible person will provide any information that is required for any mental capacity assessment and applications for DoLS authorisations, if these are required.

The admitting team should ensure the adult has an opportunity to discuss their care and should provide the following information:

  • reason for admission;
  • how long they might need to be in hospital;
  • care options and treatment they can expect;
  • when they can expect to see the doctors;
  • the name of the person who will be their main contact (this is not necessarily the discharge coordinator);
  • possible options for getting home when they are discharged from hospital;
  • care and treatment after discharge.

3.2 The hospital based multi-disciplinary team

As soon as the adult is admitted to hospital, staff in the hospital based multi-disciplinary team will support them. The composition of the team should reflect the adult’s needs and circumstances. Members could include:

  • doctors;
  • nurses;
  • therapists;
  • mental health practitioners;
  • pharmacists;
  • dietitians;
  • specialists in the adult’s condition/s;
  • social workers;
  • housing specialists;
  • voluntary sector practitioners.

The hospital based multi-disciplinary team should work with the community based multi-disciplinary team, including the service, to provide coordinated support for adults, from hospital admission through to their discharge home.

3.3 Assessment and care planning

As soon as the adult is admitted to hospital, intermediate care or step-up facilities, all relevant practitioners should start assessing their health and social care needs. They should also start discharge planning, if assessments have already been conducted in the community for which they should refer to the adult’s existing care and support plan.

A comprehensive assessment of people with complex needs should start at the point of admission and preferably in a specialist unit.

4. Hospital Stay

Multi-disciplinary assessments, prescribed and non-prescribed medicines and individual preferences should be recorded on the electronic recording system and made accessible to the hospital, the service and community based multi-disciplinary teams, as appropriate and subject to information governance protocols.

At each shift handover and ward round, members of the hospital based multi-disciplinary team should review and update the adult’s progress towards discharge.

Hospital based practitioners should keep adults, their carers and relevant staff from the service regularly updated about any changes to their plans for transfer from hospital.

Adults should be encouraged to follow their usual daily routines as much as possible during their hospital stay.

5. Planning for Discharge from Hospital

5.1 Discharge coordinator

A single health or social care practitioner should be responsible for coordinating the adult’s discharge from hospital. The discharge coordinator is a central point of contact for health and social care practitioners, the adult, their family and designated service staff during discharge planning. The discharge coordinator should be involved in all decisions about discharge planning.

5.2 Communication and information sharing

This section provides information for service staff about the responsibilities of hospital staff in relation to planning an adult’s discharge.

Health and social care organisations should have clear discharge planning protocols. All health and social care practitioners receive regular briefings on the discharge planning protocols.

During discharge planning, the discharge coordinator should share assessments and updates on the adult’s health status, including medicines information, with both the hospital and community based multi-disciplinary teams and including the relevant service staff.

The hospital based doctor responsible for the adult’s care should ensure that the discharge summary is made available to the adult’s GP within 24 hours of their discharge. They should also ensure a copy is given to the adult and the service on the day they are discharged.

A member of the hospital based multi-disciplinary team should be responsible for providing carers with information and support. This could include:

  • printed information;
  • face to face meetings;
  • phone calls;
  • hands on training, including practical support and advice.

The discharge coordinator should provide adults, their families and the relevant member of staff in the service, with details of who to contact about medicine and equipment problems that occur in the 24 hours after discharge.

6. Discharge to Assess

See also Quick Guide: Discharge to Assess (Department of Health and Social Care et al)

Wherever possible,people should be discharged from hospital to be supported in returning home, and for their assessment to be carried out in their own environment. Implementing a ‘discharge to assess’ model where going home is the norm, with alternative pathways for people who cannot go straight home, should be the desired outcome.

Whilst people can often be clinically fit to be discharged and not require an acute hospital bed, they may still require care and support services to enable them to be discharged to their own home or another community setting. In this model, assessment for longer term care and support needs is conducted in the setting and at the time most appropriate for the person. This does not detract from the need for a multi-agency assessment, nor from the requirement to ensure safe discharge.

Principles of discharge to assess, noted in Quick Guide: Discharge to Assess (see link above) include:

  • the assessment should be done promptly (within 2 hours of discharge), with rapid (on the day) access to care and support if required;
  • support services should be time limited, usually up to six weeks, although this can be extended in exceptional circumstances;
  • services should be free at the point of delivery, regardless of ongoing funding arrangements.

7. Discharge Planning for End of Life Care Needs

See also End of Life Care.

Adults in the service needing end of life care should be offered both general and specialist palliative care services, according to their needs.

The named consultant responsible for their end of life care should consider referring them to a specialist palliative care team before they are transferred from hospital.

The discharge coordinator should ensure that adults who have end of life care needs are assessed and the required support is in place so they can die in their preferred place, wherever possible.

The discharge coordinator should liaise with the service to whom they will be discharged, in relation to the additional care and support they will require upon discharge.

8. People at Risk of Hospital Readmission

The discharge coordinator should refer adults at risk of hospital readmission to the relevant community based health and social care practitioners and liaise with the service before they are discharged.

9. Discharge from Hospital

This section provides information for service staff about the principles of discharge from hospital to ensure a safe and timely return to the service, and the responsibilities of all those involved in discharging patients from hospital. See also Section 6, Discharge to Assess.

9.1 Introduction

Effective hospital discharge planning is vital in order to ensure:

  • the safe discharge from NHS hospital care arranged by the NHS to the service, including supported living;
  • that patients are not delayed in hospital despite being fit for discharge;
  • reduce the risk of unnecessary readmission to hospital;
  • the wellbeing of the adult, and delay or prevent further care and support needs.

A delayed discharge not only impacts on the individual and their family, but also on the ability of the hospital to provide services to others, preventing them from accessing hospital care essential to their care and support needs. It also impacts on the service, in terms of trying to effectively plan for the adult’s return.

9.2 Key principles

Good discharge planning:

  • ensures continuity of care for adults being transferred from hospital, particularly for those with complex need and adults who may be confused or who have dementia.
  • ensures that adults do not have to make decisions about any required changes to their current placement while they are in crisis;
  • ensures that any pressure to make beds available does not result in unplanned and uncoordinated hospital discharges.

9.3 Training and development

All relevant service staff should be trained in the hospital discharge process. Training should take place as early as possible in the course of their employment, with regular updates. It could include:

  • interdisciplinary working between the hospital and community-based multi-disciplinary teams, including working with people using services and their carers, care homes and supported living staff;
  • discharge communications;
  • how to get information about the adult’s medical condition and which staff in the service colleagues and partner agencies should liaise with;
  • how to have sensitive discussions with people about end of life care, where relevant;
  • medication review in partnership with the adult, including medicines optimisation and adherence;
  • helping adults to manage risks effectively so that they can still do things they want to do (risk enablement);
  • how to arrange, conduct or contribute to assessments for health and social care eligibility.

9.4 Discharge planning

From admission, or earlier if possible, the hospital and community based multi-disciplinary teams, including relevant staff in the service, should work together to identify and address factors that could prevent a safe, timely transfer of care from hospital. For example:

  • safeguarding issues;
  • the need for any assessments for eligibility for health and social care funding, due to a change in circumstances.

The discharge coordinator should work with the hospital, community based multi-disciplinary teams, the relevant service staff, the adult receiving care and their family, in order to develop and agree a discharge plan.

The discharge coordinator should ensure that the discharge plan takes account of the adult’s social and emotional wellbeing, as well as the practicalities of daily living. It should include:

  • details about the adult’s condition;
  • information about their medicines;
  • contact information if there should be any problems after discharge;
  • arrangements for additional care and support;
  • arrangements for continuing health support;
  • details of other useful community and voluntary services.

The discharge coordinator should give the plan to the adult, the service and all those involved in their ongoing care and support, including families and carers as appropriate.

The discharge coordinator should arrange follow up care. In addition to the service, the coordinator should identify practitioners as required (from primary health, community health, social care and the voluntary sector) and family members who will provide extra support when the adult is discharged and record their details in the discharge plan.

The discharge coordinator should discuss the need for any specialist equipment and support with service staff and also primary health, community health, and social care practitioners as soon as discharge planning starts to ensure that any essential specialist equipment and support is in place at the point of discharge.

Once assessment for discharge is complete, the discharge coordinator should agree the plan for ongoing treatment and support with the service and the community based multi-disciplinary team.

A relevant health or social care practitioner or member of staff of the service should discuss with the adult (as appropriate) how they can manage their condition after their discharge from hospital. Support and education, including coaching, should be provided if needed. This should be made available for carers as well as for adults, as appropriate.

Where appropriate, self-management should be considered as part of a treatment package for adults with depression or other mental health difficulties.

10. After Transfer from Hospital

An appropriately skilled practitioner should follow up adults, including those with palliative care and support needs, and in conjunction with the relevant member of staff in the service, within 24 hours of their transfer from hospital to agree plans for their future care.

A GP or community based nurse should phone or visit adults at risk of readmission 24–72 hours after their discharge.