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

Glossary

Advance care plan

An advance care plan could include:

Discharge plan

A document that describes the coordination of care and support for discharge from hospital. It is a working document for the multidisciplinary teams.

Discharge summary

A summary of what happened during admission and the hospital stay from a medical perspective. It might include the diagnosis, outcomes of investigations, changes to treatment and the medicines started or stopped, or dosage changes and the reasons why.

Early supported discharge

A multidisciplinary service that aims to allow patients to return home from hospital early and receive more rehabilitation support at home.

Hospital passport

A document for people who have a learning disability. It provides hospital staff with information to help with care planning and discharge arrangements.

Medication review

A structured, critical examination of a person's medicines. The aim is to agree the treatment with them, make sure the medication is being used effectively, minimise medication‑related problems and reduce waste.

Medicines optimisation

A person‑centred approach to safe and effective medicines use, to ensure that people get the best possible outcomes. Covers both prescription and non‑prescription medicines.

Medicines reconciliation

Identifying the most accurate list of a person's current medicines – including name, dosage and frequency – and comparing them with the medicines the person is taking. The aim is to spot any discrepancies and document any changes to ensure that the list is complete, up to date and accurately communicated.

Step‑up facilities

Intermediate care settings that people are referred to from community settings. The aim is to prevent unnecessary acute hospital admissions or premature admissions to long‑term care.

Supportive self‑management

Supportive self‑management is based on the principle that people should be active partners in supporting their own health and wellbeing, rather than being passive recipients of care. Self‑management techniques help people build the confidence to make informed decisions about their own health and social care and reach any related goals.