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

See everyone receiving care as 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.

Identify and support people at risk of less favourable treatment or with less access to services for example, people with communication difficulties or who misuse drugs or alcohol. Support may include help to access advocacy.

Involve families and carers in discussions about the care being given or proposed if the person gives their consent. If there is doubt about the person's capacity to consent, the principles of the Mental Capacity Act must be followed.

Ensure that the person, their carers and all health and social care practitioners involved in someone's move between hospital and home are in regular contact with each other. This is to ensure the transition is coordinated and all arrangements are in place. For more on medicines‑related communication and medicines reconciliation during transitions, see sections 1.2 and 1.3 in NICE's guideline on medicines optimisation and section 1.3 in NICE's guideline on managing medicines in care homes.

Give people information about their diagnoses and treatment and a complete list of their medicines when they transfer between hospital and home (including their care home). If appropriate, also give this to their family and carers.

Offer information in a range of formats, for example:

• verbally and in written format (in plain English)

• in other formats that are easy for the person to understand such as braille, Easy Read or translated material (see NHS England's Accessible Information Standard).

Develop and use communication protocols and procedures to support admissions.

The admitting team should identify and address people's communication needs at the point of admission. For more information on communication needs see recommendation 1.1.2 in NICE's guideline on patient experience in adult NHS services.

Health and social care practitioners, including care home managers and out‑of‑hours GPs, responsible for transferring people into hospital should ensure that the admitting team is given all available relevant information. This may include:

• advance care plans

• behavioural issues (triggers to certain behaviours)

• care plans

• communication needs

• communication passport

• current medicines

• hospital passport

• housing status

• named carers and next of kin

• other profiles containing important information about the person's needs and wishes

• preferred places of care.

For an emergency admission, A&E should ensure that all available, relevant information is given to the admitting team when a person is transferred for an inpatient assessment or to an admissions ward.

The admitting team should provide the person and their family, carer or advocate with an opportunity to discuss their care. Also 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.

The admitting team must identify whether there is a need for reasonable adjustments to be made to accommodate the person in hospital. This is in line with the Equalities Act 2010. Examples include:

• providing communication aids (this might include an interpreter)

• ensuring there is enough space around the bed for wheelchair users to move from their bed to their chair

• appropriate adjustments for carers.

As soon as the person is admitted to hospital, identify staff to form the hospital‑based multidisciplinary team that will support them. The composition of the team should reflect the person's needs and circumstances. Members could include:

• doctor

• nurse

• therapists

• mental health practitioner

• pharmacist

• dietitian

• specialists in the person's conditions

• social worker

• housing specialist

• voluntary sector practitioners.

The hospital‑based multidisciplinary team should work with the community-based multidisciplinary team to provide coordinated support for older people, from hospital admission through to their discharge home.

As soon as people with complex needs are 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, refer to the person's existing care plan.

Start a comprehensive assessment of older people with complex needs at the point of admission and preferably in a specialist unit for older people.

Make a single health or social care practitioner responsible for coordinating the person's discharge from hospital. Create either designated discharge coordinator posts or make members of the hospital‑ or community-based multidisciplinary team responsible. Select them according to the person's care and support needs. A named replacement should always cover their absence.

Ensure that the discharge coordinator is a central point of contact for health and social care practitioners, the person and their family during discharge planning. The discharge coordinator should be involved in all decisions about discharge planning.

Health and social care organisations should agree clear discharge planning protocols.

Ensure that 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 person's health status, including medicines information, with both the hospital‑ and community‑based multidisciplinary teams.

The hospital‑based doctor responsible for the person's care should ensure that the discharge summary is made available to the person's GP within 24 hours of their discharge. Also ensure that a copy is given to the person on the day they are discharged.

Make a member of the hospital‑based multidisciplinary team 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 people who need end‑of‑life care, their families and carers with details of who to contact about medicine and equipment problems that occur in the 24 hours after discharge.

The discharge coordinator should consider providing people with complex needs, their families and carers, with details of who to contact about medicine and equipment problems that occur in the 24 hours after discharge.

Ensure continuity of care for people being transferred from hospital, particularly older people who may be confused or who have dementia. For more information on continuity of care see the recommendations in section 1.4 of NICE's guideline on patient experience in adult NHS services.

Ensure that people do not have to make decisions about long‑term residential or nursing care while they are in crisis.

Ensure that any pressure to make beds available does not result in unplanned and uncoordinated hospital discharges.

From admission, or earlier if possible, the hospital‑ and community‑based multidisciplinary teams should work together to identify and address factors that could prevent a safe, timely transfer of care from hospital. For example:

• homelessness

• safeguarding issues

• lack of a suitable placement in a care home

• the need for assessments for eligibility for health and social care funding.

The discharge coordinator should work with the hospital‑ and community‑based multidisciplinary teams and the person receiving care to develop and agree a discharge plan.

The discharge coordinator should ensure that the discharge plan takes account of the person's social and emotional wellbeing, as well as the practicalities of daily living. Include:

• details about the person's condition

• information about the person's medicines

• contact information after discharge

• arrangements for continuing social care support

• arrangements for continuing health support

• details of other useful community and voluntary services.

The discharge coordinator should give the plan to the person and all those involved in their ongoing care and support, including families and carers (if the person agrees).

The discharge coordinator should arrange follow‑up care. They should identify practitioners (from primary health, community health, social care, housing and the voluntary sector) and family members who will provide support when the person is discharged and record their details in the discharge plan.

The discharge coordinator should discuss the need for any specialist equipment and support with primary health, community health, social care and housing practitioners as soon as discharge planning starts. This includes housing adaptations. 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 community‑based multidisciplinary team.

A relevant health or social care practitioner should discuss with the person how they can manage their condition after their discharge from hospital. Provide support and education, including coaching, if needed. Make this available for carers as well as for people using services.

Consider supportive self‑management as part of a treatment package for people with depression or other mental health difficulties.

Ensure that people needing end‑of‑life care are offered both general and specialist palliative care services, according to their needs.

The named consultant responsible for a person's 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 people who have end‑of‑life care needs are assessed and support is in place so they can die in their preferred place.

Ensure that older people with identified social care needs are offered early supported discharge with a home care and rehabilitation package.

Consider early supported discharge with a home care and rehabilitation package provided by a community‑based multidisciplinary team for adults with identified social care needs.

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

If a person is homeless, the discharge coordinator should liaise with the local authority housing options team to ensure that they are offered advice and help.

The hospital‑ and community‑based multidisciplinary teams should recognise the value of carers and families as an important source of knowledge about the person's life and needs.

With the person's agreement, include the family's and carer's views and wishes in discharge planning.

If the discharge plan involves support from family or carers, the hospital‑based multidisciplinary team should take account of their:

• willingness and ability to provide support

• circumstances, needs and aspirations

• relationship with the person

• need for respite.

A member of the hospital‑based multidisciplinary team should discuss the practical and emotional aspects of providing care with potential carers.

Ensure that training is available to help carers provide practical support. The relevant multidisciplinary team should offer family members and other carers of people who have had a stroke needs‑led training in how to care for them. For example, this could include techniques to help someone carry out everyday tasks as independently as possible. Training might take place in hospital or it may be more useful at home after discharge.

The relevant multidisciplinary team should consider offering family members and other carers needs‑led training in care for people with conditions other than stroke. Training might take place in hospital or it may be more useful at home after discharge.

The community‑based multidisciplinary team should review the carer's training and support needs regularly (as a minimum at the person's 6‑month and annual reviews). Take into account the fact that their needs may change over time.

Community‑based health and social care practitioners should maintain contact with the person after they are discharged. Make sure the person knows how to contact them when they need to.

An appropriately skilled practitioner should follow up people with palliative care needs 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 people at risk of readmission 24–72 hours after their discharge.