Guidance

Hospital discharge and community support: staff action cards (all roles)

Updated 27 October 2022

Applies to England

This document contains all the hospital discharge and community support staff action cards.

It outlines how your role helps to implement best practice outlined in the hospital discharge and community support guidance.

Each action card should be read along side the key messages for all staff.

Medical staff (doctors) action card

All people who no longer meet the clinical criteria to reside for inpatient care in acute hospitals should be discharged home or to a non-acute setting as soon as it is possible and safe to do so.

Reviews and discharge co-ordination

• ensure twice daily multi-disciplinary review (consultant review at least daily) of all people in acute beds - agree who no longer meets the clinical criteria to reside for inpatient care and therefore should be discharged
• ensure clear clinical plans in medical notes to enable criteria-led discharge
• request immediate arrangements for discharge with a plan for virtual follow-up where needed.
• people should be discharged when clinically ready in a safe and timely manner
• if a person ready for discharge requires onward care and support, it is best practice for them to receive a short period of post-discharge rehabilitation and/or reablement prior to any assessments of ongoing care and support needs (if required), this is to ensure accurate assessments of longer-term needs
• the multi-disciplinary team should clearly describe the function and needs of people ready for discharge - they should not prescribe the exact post-discharge care and support needed
• ensure e-discharge summaries shared with GPs contain pertinent information from the hospital episode, and the discharge details and plan, including any medication instructions and safety netting arrangements

Safety netting

• conduct patient-initiated follow-up. Give people the direct number of the ward they are discharged from to call back for advice. Do not suggest going back to their GP or going to the emergency department
• if required, telephone people the day after discharge to check on them
• if required, call people after discharge with the results of investigations and their management plan
• manage people virtually in outpatient clinics under the care of the same team or speciality
• request community nursing and/or GP follow-up where appropriate

Criteria-led discharge

• for each person selected for criteria-led discharge, document clear clinical criteria for safe discharge that can be enacted by an appropriate junior doctor, nurse or allied health professional without further consultant review. These may be used alongside the clinical criteria to reside in acute hospitals

• ensure arrangements are in place to contact the consultant directly for clarification about small variances from the documented clinical criteria

Matron, ward manager (nurse in charge) action card

All people who no longer meet the clinical criteria to reside for inpatient care in acute hospitals should be discharged home or to a non-acute setting as soon as it is possible and safe to do so.

What you need to do

• ensure twice daily multi-disciplinary review (consultant review at least daily) of all people in acute beds - agree who no longer meets the clinical criteria to reside for inpatient care and therefore should be discharged
• ensure every person has a clearly written plan which includes clear clinical criteria by which a person no longer meets the criteria to reside. Make sure the plan is communicated to all multi-disciplinary team members, the person and their carers, family and friends. A patient leaflet is available to give people on admission
• for those likely to require health and/or social care and support following discharge, you must ensure that the person and any unpaid carers (including young carers) are involved in early discharge planning conversations, where appropriate, as per the duty in the Health and Care Act 2022
• the multi-disciplinary team (MDT) should clearly describe the function and needs of people ready for discharge, for example, where someone would need help for daily activities such as preparing meals. They should not prescribe the exact post-discharge care and support needed
• where discharge to assess is implemented, liaise with managers of the discharge or relevant team in relation to people on pathway 0 (those discharged home without formal care and support)
• for discharges to care homes, ensure the results of COVID-19 testing within 48 hours prior to discharge are shared with individuals themselves, their family members or carers and relevant care providers in advance of discharge
• ensure staff nurses are engaged in good discharge practice, for example, utilising the Home First, Act Now elearning programme

• during every ward round, board round or case discussion ask the following:

  • does the person require the level of care that they are receiving, or can it be provided in another setting?
  • what value are we adding for the person staying in the acute hospital balanced against the risks of them being discharged?
  • what do they need next and what action is required?
  • ‘why not home, why not today?’ For those who have not reached a point where long-term 24-hour care is required
  • ‘if not for discharge today, then when?’ Ensure there is an expected date of discharge
  • can a nurse or allied healthcare professional discharge the patient without a further review if documented clinical criteria are met?

Acute therapy teams action card

A significant part of your work should now be in non-acute settings (mainly in people’s homes).

What you should do differently

• where discharge to assess is implemented, limited assessments for discharge should be undertaken on a ward or other acute hospital setting or designated therapy assessment area
• if following the discharge to assess model, prompt assessments of short-term recovery care and support needs (and after a period of recovery, assessments of long-term or ongoing care and support needs) should take place after discharge in non-acute settings (mainly in people’s homes)
• work alongside adult social care colleagues to agree a recovery and support plan with the person and their family members or carers, including reablement and equipment
• assessments should be trusted assessments and should therefore be accepted by any receiving care providers (a universal document to be used across acute and community services should be agreed)

When and where you should do your work

• you should work much more fluidly between community settings, people’s homes and within the acute trust, depending on demand and capacity and learning from the pandemic
• cover should continue to be required 7 days a week, so you may find your hours of work are adjusted

Case manager role (where appropriate)

• it is best practice for the transfer of care hub to direct (for each person) who should be the case manager to aid and monitor a person’s discharge and recovery

• acute therapists may particularly, but not exclusively, undertake the case manager role for people who:

  • have rehabilitation needs following illness or trauma
  • require help to manage and self-manage long-term conditions
  • have progressive illnesses where interventions can help them to maintain their independence for as long as possible

Bedded rehabilitation (therapies) action card

You will need to decrease the overall length of stay to create more capacity and allow more people to benefit from rehabilitation. Your work may now have a greater focus on community outreach.

How you should work differently with colleagues

• there should be a case manager assigned to each person and acting on behalf of the local health and social care system who should liaise directly with your unit to facilitate the discharge
• there should be an increase in the availability and timeliness of relevant services within the community to help people regain autonomy at home

What you should do differently

• start a daily clinical review (10 to 20 minutes) of the plan for every person focussing on the key questions:

  • why not home?
  • what needs to be different so they can go home?
  • why not today?
• assess people for discharge against the clinical criteria to reside for inpatient care in community beds
• use discharge to assess pathways as a best-practice model for discharge routes from community rehabilitation beds, where such pathways are in place locally
• act as a trusted assessor for onward referrals. You should not expect to have to re-do assessments, or to use lengthy referral forms
• you may use technology for outreach and follow-up to reduce travel time
• all equipment and care needs should be assessed within the person’s home using the locally agreed routes
• you should update the national capacity tracker with your bed status to help the management of overall NHS bed capacity

When and where you should do your work

• you may be required to provide outreach support to a person in the community – the transfer of care hub should direct the process
• cover will continue to be required 7 days a week so you may find your hours of work are adjusted

Adult social care teams action card

A significant part of your work should now be in non-acute settings (mainly in people’s homes), working alongside therapists to support people, mainly in their own homes.

What you should do differently

• where discharge to assess is implemented, limited assessments for discharge should be undertaken on a ward or other acute hospital setting. Acute-based safeguarding investigations should continue
• where practical, agree a single lead local authority contact who should work with or as part of the transfer of care hub
• work alongside acute therapists to assess people for short-term care and support needs to aid recovery at the request of the transfer of care hub and agree a recovery and support plan with the person and their family members or carers, including reablement and equipment
• coordinate with housing and local and national voluntary sector organisations to provide services and support to people on discharge
• use assistive technologies (telehealth and telecare), where helpful. The use of equipment may help to reduce double-handed care to single-handed care
• work with unpaid carers, providing them with support and undertaking a carer’s assessment where needed. Children who are young carers should be referred for young carers needs assessments or young carers support services as appropriate
• where discharge to assess is implemented, conduct Care Act (2014) assessments of long-term or ongoing social care needs and funding eligibility after discharge, in non-acute settings, and at the end of the recovery period, if required

When and where you should do your work

• an adult social care presence in the acute trust should be reduced, but ASC staff will still need to work closely with acute colleagues and some presence will be required. An ASC presence in community hospitals should be agreed to support recovery as part of MDT working. ASC staff input into transfer of care hubs should be over 7 days

Case Manager manager role (where appropriate)

• it is best practice for the transfer of care hub to direct (for each person) who should be the case manager to aid and monitor a person’s discharge and recovery

• social workers may particularly, but not exclusively, undertake the case manager role for people who:

  • have complex capacity issues
  • have identified safeguarding risks

How you should work differently with colleagues

• in general, do not undertake social care needs or funding assessments in the acute hospital. Acute-based safeguarding investigations should continue
• where practical, agree a single lead local authority point of contact for each hospital site who should work as part of the transfer of care hub to coordinate care and support to people to aid discharge and recovery, as well as admission avoidance
• coordinate with housing and local and national voluntary sector organisations to provide services and support to people on discharge
• work with unpaid carers, providing them with support for caring for others and undertaking a carer’s assessment where needed. Children who may be young carers should be referred for young carers needs assessments or young carers support services as appropriate
• conduct Care Act (2014) assessments of long-term social care needs and funding eligibility, at the end of the recovery period, if required

When and where you should do your work

• an adult social care (ASC) presence in the acute trust should be reduced but ASC staff will still need to work closely with acute colleagues and some presence, probably in the form of a senior social worker, will be required

Case manager role (where appropriate)

• the transfer of care hub should direct (for each person) who should be the case manager to aid and monitor a person’s discharge and recovery
• social workers may particularly, but not exclusively, undertake the case manager role for people who:
  • have complex capacity issues
  • have no recourse to public funds
  • have identified safeguarding risks

Local system commissioners action card

If not already in place, you should establish a single collaborative commissioning route for domiciliary care and care homes in relation to discharge with one lead commissioner, where appropriate locally.

How you should work differently with colleagues

• you should establish a collaborative commissioning approach and identify a lead commissioner, where appropriate locally. See Effective commissioning for a Home First approach (PDF, 374 KB) and Top tips for collaborative commissioning
• you should jointly agree a place-based vision and commissioning priorities based on the needs of your community and avoidance of unnecessary hospital admissions and readmissions
• you should consider what reshaping of the market is necessary to support a Home First approach and prevention and early intervention to enable people to live independently at home for longer. Any market reshaping should be sustainable
• the lead commissioner should work with the single coordinator to ensure issues in relation to flow through commissioned services are addressed

What you should do differently

• expand NHS at home (for example telecare and telehealth) where possible
• support greater use of personal health budgets and individual service funds to support mainstream care at home by directly employed carers
• where discharge to assess is implemented, establish contractual options to maintain continuity of care from providers supporting pathway 1 people at home when the period of care is completed

When and where you should do your work

• you are likely to work much more closely with people engaged in different elements of the commissioning process from other organisations as part of a collaborative commissioning approach
• you are likely to need to work more flexibly to support the new requirements. Cover will continue to be required 7 days a week

Managers of the discharge team action card

A significant part of your work should now be co-ordinating care input and oversight in non-acute settings (mainly in people’s homes).

How you should work differently with colleagues

• where discharge to assess is implemented, you may continue to liaise with wards in relation to people on pathway 0 (those discharged home without formal care and support). In some acute hospitals another team may be responsible for discharge of those on pathway 0
• it is advised that you work as part of the transfer of care hub in relation to people on pathways 1, 2 and 3 (those requiring health and/or social care and support following discharge)
• homeless people and people at risk of homelessness should be referred to the local authority. Mental health clinicians should be consulted for people with mental health need

What you should do differently

• where discharge to assess is implemented, arrange dedicated staff to manage pathway 0 discharges, if responsible
• if following the discharge to assess model, ensure case managers, working with the transfer of care hub, coordinate an initial safety and welfare check on the day of discharge for people on pathways 1, 2 and 3; and ensure these people are assessed promptly for short-term care and support needs to aid their recovery in their discharge destination (usually their own home or usual place of residence)
• it is advised that you ensure there is adequate capacity amongst case managers assigned to people on pathways 1, 2 and 3 to enable them to monitor progress against recovery and support plans and ensure assessments of any long-term or ongoing care needs (if required) are undertaken as soon as it is possible to get an accurate picture
• you must ensure that any unpaid carers (including young carers) are involved in early discharge planning conversations, where appropriate, as per the duty set out in the Health and Care Act 2022 (applicable from July 2022)

When and where you should do your work

• you should work much more fluidly between community settings and within the acute trust, depending on demand and capacity and learning from the pandemic
• cover will continue to be required 7 days a week so you may find your hours of work are adjusted

Members of the discharge team action card

Where discharge to assess is implemented, you should continue discharging people on pathway 0 (straight home without formal care and support) if responsible. A significant proportion of your work should be focused on discharging people on pathways 1, 2 and 3 (those requiring health and/or social care and support following discharge).

How you should work differently with colleagues

• where discharge to assess is implemented, you should supplement ‘discharge to assess’ capacity, working as part of and directed by the transfer of care hub, and supported by your line manager
• homeless people and people at risk of homelessness should be referred to the local authority. Mental health clinicians should be consulted for people with mental health needs

What you should do differently

Responsibilities could include (this is not an exhaustive list and will depend on local arrangements and individual skillsets):

• accompanying people to the discharge lounge and, on discharge, accompanying people home or to a non-acute setting
• acting as a trusted assessor for care homes and community bed settings
• supporting people to manage their own recovery by identifying and activating their knowledge, skills and confidence
• supporting the effective flow of people

When and where you should do your work

• you are likely to need to work more flexibly to support the new requirements. Cover will continue to be required 7 days a week

Single coordinator action card

Every local health and social care system based around an acute hospital site should have a single coordinator to lead and drive the discharge agenda across the system.

The single coordinator should report to a named executive lead.

The single coordinator may be employed by any organisation in the system and can be from any professional background.

In performing this system leadership role, you should develop a shared system view of discharge, hold all parts of the system to account and drive system actions to address shared challenges. Your remit may also encompass admission avoidance if this makes sense locally.

Critical success factors

A common purpose and shared vision – for example, a clear and consistent focus on discharge to assess and Home First where implemented locally – will help to generate commitment from all partners:

• you should work closely at operational level to ensure safe and timely discharge on the appropriate pathway for all individuals
• you will need to work with and for the whole system and not be seen to belong to or represent one area
• you should quickly develop a working understanding of how a therapy-led approach can support timely and effective discharges

Enough decision-making authority – this will not only shape how quickly change can be made but also its impact:

• you should identify and remove blockages and, where necessary, change processes across the whole system
• you should use your personal attributes and position as a senior member of staff to bring about change

Sphere of control – this will determine how your role can bring about change, whether through direct decision-making or by influencing:

• you should direct discharge support services in the acute and community
• you should use conflict management skills as you make changes that best serve people rather than systems
• you should work at a micro and macro level and intervene in individual cases and change the overall process where required

Working with partners – working with partners earlier rather than later will make for more credible implementation:

• you should deploy co-design and codelivery with all stakeholders
• where implemented, you should promote ‘the vision’ of a successful D2A model and Home First approach across the whole system

Case manager action card

A case manager may be assigned to each person requiring post-discharge health and/or social care and support to aid and monitor their discharge and recover.

Where discharge to assess is implemented, the transfer of care hub should decide which pathway (1, 2 or 3) is the best for the person and assign the case manager.

The case manager may be employed by any organisation in the system and can be from any professional background – the case manager may change throughout a person’s journey depending on the person’s needs.

Where discharge to assess is implemented, you should be assigned to people on pathways 1, 2 and 3 to aid and monitor their discharge and recovery.

Discharge from the ward

• ensure the person and any carers, family or friends are involved in and informed about what is happening and when. Patient leaflets are available for people being discharged home or discharged to a care home. A leaflet for carers is also available including information about a carer’s right to a carer’s assessment
• ensure transport home, or elsewhere, has been organised and any medications to take out (TTOs) have been ordered and will be ready at the point at which the person will be leaving the hospital. Confirm any safety netting with the ward
• if using a ‘settling-in’ service, liaise with the provider about timing and duration
• confirm the details of the pathway provision with the transfer of care hub, including the location, contact details, nature of the provision, and other relevant details
• work with the transfer of care hub to ensure an initial safety and welfare check takes place on the day of discharge, liaising with family members or carers and relevant care providers

Monitoring

• in liaison with the multi-disciplinary team providing support to the person, closely monitor and document progress against the recovery and support plan
• ensure adjustments are made to the support provided as required and in a timely way and the support is ended when it is no longer needed

Assessment of long-term needs

Where discharge to assess is implemented after a sufficient period of recovery, where it appears a person may need support on a long-term basis, liaise with appropriate professionals to ensure timely assessment for example, a Care Act (2014) assessment, and/or NHS continuing healthcare assessment. Case managers would not usually carry out these assessments.

Transfer of care hub action card

The transfer of care hub is the local health and social care system-level coordinating centre (fully or partially co-located with acute settings where suitable) linking all relevant services across sectors to aid discharge and recovery and admission avoidance.

Every local health and social care system based around an acute hospital site should have a transfer of care hub to link a wide-range of health and social care and wider services.

The hub should play a key coordinating role to aid discharge and admission avoidance if this makes sense locally due to overlapping services and staff.

The hub should operate 7 days a week, ensuring discharges are timely and urgent community response standards are met.

What the transfer of care hub is

• a system-level place whereby (physically and/or virtually) all relevant services (for example, acute, community, primary care, social care, housing and voluntary) are linked in order to coordinate care and support for people who need it – during and following discharge and to prevent acute hospital admissions

• responsible for developing timely and person-centred ‘step-down’ or ‘step-up’ plans for people based on the principle of ‘no place like home’

Discharge and recovery role

• supports safe discharges through close working with the acute wards, quality assurance of information and practical support, including early identification of people who may become ready for discharge
• where discharge to assess is implemented, decides which pathway each person should be placed on (1, 2 or 3) based on the description of the person received from acute wards; also assigns a case manager to each person
• works with the assigned case manager to ensure an initial safety and welfare check takes place on the day of discharge
• coordinates and arranges the recovery care support needed on discharge, liaising with family members or carers and relevant care providers, and ensures the staff and infrastructure are available to meet a person’s recovery needs
• provides information about when and how assessments of long-term needs should take place and financial implications based on a person’s identified status at assessment stage (for example, NHS continuing healthcare and NHS funded nursing care, local authority, or self-funded)

Admission avoidance role (if applicable)

• decides which pathway each person should be placed on – for example 2-hour urgent community response or other pathway – based on the information provided during the referral process