Hospital discharge and community support: key messages for all staff
Updated 27 October 2022
Applies to England
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Key messages for all staff
Early discharge planning is required from admission (for emergency admissions) and prior to admission (for elective admissions). This enables people and their family members or carers to ask questions and receive timely information to support them in discussions and decisions about their discharge. For those likely to require health and/or social care and support post-discharge, early discharge planning must involve the person and any unpaid carers (including young carers), where appropriate, as per the duty in the Health and Care Act 2022.
All people who no longer meet the clinical criteria to reside for inpatient care in acute hospitals or who no longer need inpatient care in community hospitals should be discharged as soon as it is possible and safe. Local areas should adopt discharge processes that best meet the needs of the local population. This could include the discharge to assess model and home first approach.
Every local health and social care system based around an acute hospital site should have a single coordinator, reporting to an executive lead, to lead and drive the discharge agenda across the system.
Where discharge to assess is implemented, discharge home should be the default pathway (pathways 0 and 1). People may also be transferred to non-acute settings (pathways 2 and 3). A case manager may be assigned to all those requiring health and/or social care and support post-discharge to aid their recovery prior to any assessments of ongoing needs (pathways 1, 2 and 3). A transfer of care hub based around an acute hospital site should link services to coordinate care and support to aid discharge, recovery and admission avoidance.
People should be discharged as soon as it is possible and safe following a medical decision to discharge. People on all pathways should be discharged as early in the day as possible, ideally before 5pm, as agreed with people and their family members or carers and any providers of onward care and support.
Staff training is available via the Home First Act Now eLearning Programme. For the latest information on COVID-19 requirements for people discharged to care homes, please see Infection prevention and control in adult social care settings and Infection prevention and control in adult social care: acute respiratory infection.