Assessment - Hospital discharge

Getting better joined-up systems between hospitals, primary care services (GPs), and social care


There can be delays when a customer is ready for hospital discharge and their care package and personal budget need re-instatement or commencement. Delays can be due to the following reasons: transfer of paperwork between hospital, GP, and social care teams; late assessments; unavailable suitable services; Continuing Healthcare (CHC) disputes can arise and hospital staff may not have had joint training on the roles expected of them in the NHS Framework on CHC; and choice of accommodation rights can become confused if the local rate has been set arbitrarily.



What are the outcomes we want to achieve?

In Hospital

  • No long-term decisions are made immediately following hospital admissions
  • The person along with their family and/ or carer are involved in all discussions and decisions about their hospital discharge arrangements and ongoing care and support
  • They know who is the lead professional is coordinating the hospital discharge and how to contact them while in hospital
  • All professionals involved are working in partnership and have spoken together with the person to plan how to best meet their needs


  • The person, their family and/ or carer understand the options available and have been given time to consider these
  • Where appropriate the person has the option of being discharged to a more supportive environment such as an NHS funded or LA funded interim bed to give them a little more time to make a decision about long-term care and support
  • The person understands the local offer of services available to help them regain their independence


  • All parties have agreed the discharge plan and developed a short-term support plan
  • The agreed care and supports are in place when the person returns home
  • The person is able to be discharged from hospital when it is safe to do so


What tools and resources do we need to do a good job? What are the steps we have to go through?


  • The person's medical records, clinical management plan and previous assessments if relevant
  • A range of information and advice about the range of care and support options available locally, how the system works, how to access them and how to raise concerns
  • Specific information and advice on the reablement offer available and the benefits of this approach
  • A range of information to enable people to self-manage their own conditions


  • Copies of assessment, support planning and financial assessment forms and continuing healthcare checklist
  • Modular short-term assessment and support plan, that:
    • Clearly identifies short-term care and support needs
    • Clearly identified potential for reablement
    • Identifies the person's circle of support and how it can be utilised and strengthened
    • Enables agreement on:
      • Short term targets and outcomes
      • Risks
      • Risk enablement plans
  • If likely to need ongoing support following reablement
    • Eligible needs
    • Eligible unmet needs
    • Risk assessment
    • Proper application of the Mental Capacity Act at each step if the person may lack capacity to make decisions about their own care and support


  • All resources and information in preferred format
  • Lead contact for the individual
  • Independent advocacy and interpreter where relevant
  • Mobile equipment/ technology
  • Integrated care record/ system
  • Information sharing protocol
  • Clear roles and responsibilities
  • Appropriately funded interim beds including step-down and discharge to assess


What are the products we will have at the end of this process?

  • A smooth, timely and safe transition from hospital to home
  • Level of discharge and transfer planning needs identified
  • Agreed discharge date and post discharge initial review date shared with person and family/ carer
  • Completed integrated assessment of care and support needs in hospital
  • Short-term plan, goals and timescales agreed by all parties
  • Record of interaction and decision making


When does this process start and end and within what timescales should this process be completed?

  • Start planning for discharge or transfer before or on day of admission
  • Expected date of discharge appropriate to anticipated clinical pathway


Who needs to be involved and what is their role? Who is taking the lead?

  • Person
  • Family, carer or other who the person chooses to be involved
  • Independent advocate or chosen representative
  • Interpreter
  • Care coordinator/ Social worker
  • Discharge coordinators
  • Relevant professionals in hospital, e.g. OT, nurse, consultant
  • GP
  • Voluntary sector e.g. discharge home support


Combined difficulties produce delayed discharges and a disjointed and bureaucratic experience for people who use services.

In addition to these complexities, social care and health teams must consider Care Act requirements.

These are:

  • Advocacy rights on assessment and care planning
  • Choice and control principles underpinned by Choice regulations and guidance
  • Removal of mandatory fines, moving to a discretionary system
  • Support for carers
  • Quality information
  • Provision for people whose likely self-funding status may mean that they do not want or need the involvement of social services but may have CHC rights


  • Case study: Greenwich Council - Hospital discharge (pdf - 1.30Mb) (opens new window)

    The case study uses learning from the integrated discharge team in Greenwich to identify areas of success that can be replicated by other local authorities. There are five key enablers which support successful implementation of a smooth hospital discharge process:

    • Vision and leadership
    • Upfront investment for long-term benefits
    • Robust governance to support collaboration
    • Provision of quality information
    • Single team with shared Key Performance Indicators (KPIs)


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