The guideline from NICE – the National Institute for Health and Care Excellence – will ensure people with social care needs who need hospital treatment get the support they need to leave hospital in a coordinated and timely way. The guideline will also help to avoid repeated hospital stays.

• In August this year more than 5,000 people experienced delays in their discharge from hospital, up from 3,961 in 2012.
• The National Audit Office says 1 million people were readmitted to hospital as an emergency within 30 days of discharge in 2012-13, costing the NHS £2.4 billion.

The guideline, which focuses on caring for adults who are being admitted to and discharged from hospital and require social care support from community services or a residential or nursing home, calls for hospitals to appoint a single person responsible for co-ordinating an individual’s discharge.

It also says pressure on beds should not result in any unplanned or uncoordinated discharges, and commissioners of health and social care services should develop a multi-agency plan to address pressures on services, including bed shortages.

Professor Gillian Leng, deputy chief executive and director of health and social care for NICE, said: “Going into hospital can be an anxious time for many. For those with extra care needs, they may continue to worry about how they will cope when they go back home.

“A smooth and timely transition from hospital back to their home environment – whether that’s their own home or a care home – has a positive effect on a person’s wellbeing and can speed up their recovery. It should also help ease the pressure on hospitals and avoid people becoming caught in the ‘revolving door of care’ – when they are readmitted because they’re not getting the right support at home.

”Having a plan in place to ensure adequate health and social care services are available in the local community and are able to cope with any seasonal or other pressures is vital.”

The guideline also advocates health and social care practitioners working together more closely to help alleviate pressure on local services and provide seamless support when people go home.

Professor Leng continued: “Practitioners should be talking to each other, sharing information and planning discharge from the time the person is admitted or earlier if possible.

“We know that it can be challenging to coordinate a person’s discharge from hospital when they also have extra care needs. One of our recommendations is for a single person to coordinate the process for each individual to streamline and simplify the process.”

The discharge coordinator role could be specially created or the responsibility handed to a member of the multidisciplinary team looking after that particular person. It should include:

• being the main point of contact for the person using services, their family and health and social care practitioners involved in their care;
• sharing updates on the person’s health, including medicines information to all appropriate practitioners;
• working with the hospital- and community-based teams to agree a discharge plan, which should take into account the person’s social and emotional wellbeing, as well as the practicalities of daily life. This plan should be given to the person and all those involved with their care, including family members and carers;
• agreeing a plan for ongoing treatment and support with the community-based multidisciplinary team who will be providing care;
• ensuring that any specialist equipment and support is in place before the person is discharged from hospital, if it is required.

All relevant staff should also be trained in the hospital discharge process and this should be refreshed regularly.

Good communication for continuity of care

A key focus of the guideline is to encourage closer communication between health and social care teams in order to achieve a good transition between hospital and home. To facilitate this, the guideline recommends:

• GPs and other relevant practitioners who are responsible for transferring people to hospital (including care home managers) sharing all appropriate information with the hospital when a person with social care needs is admitted for treatment.
• hospitals bringing together a team of multidisciplinary professionals as soon as a person with social care needs is admitted to hospital, to look after them. Members should be best placed to care for the person’s individual needs and circumstances;

• health and social care practitioners recording information about medicines, assessments and individual preferences in an electronic data system, accessible to everyone who is providing care;
• the community-based multidisciplinary team maintaining contact  with the person after they are discharged, for instance through regular phone calls and home visits. The person being cared for should also know how to contact their community-based health and social care team after they have left hospital;
• a community-based nurse or GP calling or visiting people at risk of hospital readmission 24 to 72 hours after discharge.

The guideline also makes recommendations on the care that specific groups of people should receive when they are ready to leave hospital, such as older people with complex needs, those with depression and individuals requiring end-of-life care.

Kathryn Smith, Director of Operations for the Alzheimer’s Society and Chair of the independent committee which developed the guideline, said: “Timely and appropriate discharge from hospital is essential to achieving high-quality, seamless care that’s right for the individual. A stay in hospital away from familiar surroundings can be a very stressful time for anyone, particularly people with living with dementia.

“Plans for discharge should be made with the individual to ensure that they are going to the place that’s right for them – whether that’s home or residential care. Effective planning should ensure that discharge is safe and at the appropriate time, for example during the week, when it may be easier to arrange care. We encourage comprehensive and specialist assessment of complex needs; close communication between everyone involved in the individual’s care; and that discharge is supported through social care and reablement, where needed.  

“Nearly all of the 850,000 people living with dementia in the UK will require care and support from both the NHS and social care system at some point in their lives – people with dementia account for around 3.2 million hospital bed days per year. We hope that this new guidance will support the health and social care system to provide continuous care that’s tailored to the individual, wherever they are.”

Anna Bradley, Chair of Healthwatch England, said: "Everyone should experience a safe, dignified and well planned transfer of care; however our special inquiry into unsafe discharge, "Safely Home", found that sadly this is often not the case. We therefore welcome this new guidance from NICE.

"We heard shocking stories which highlighted how poor co-ordination of health and social care services and a failure to put patients at the heart of discharge planning is resulting in far too many people being kept in hospital longer than necessary, as well as many being discharged too early and being readmitted to hospital soon after. This comes at a huge human and financial cost.

"All staff across both health and social care need to commit to involving patients and their loved ones in planning how and when they are going to leave hospital from the very first moment they are admitted.

“We are pleased that the system is starting to take steps to make improvements as set out in our discussions with the Department of Health earlier this year. We hope this new NICE guidance will help focus providers and professionals on working together to ensure that people are not falling through the gaps in health and social care and left without adequate care and support this winter."

Tony Hunter, Chief Executive of the Social Care Institute for Excellence (SCIE), said: “It’s really good that the guideline focuses on what should happen in hospital, from admission onwards and throughout someone’s stay, so that their discharge isn’t rushed or unplanned. We’re keen to encourage good collaboration between health and social care and people’s experience of transition between hospital and home is a key indicator on how well integration is working.

“As the lead partner in the NICE Collaborating Centre for Social Care, we were very pleased to have the opportunity to work on this. The guideline helps by providing a joint script and practical advice with clear and specific recommendations for health and social care staff working in hospitals and the community, often in testing circumstances. It includes recommendations about early communication between hospital and community staff and about making sure people and their families are kept informed throughout their stay in hospital and have all the information they need when they go home.”

Ends

For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.

Notes to Editors

Explanation of terms

1. A delayed transfer of care occurs when a patient is medically fit for discharge, but is still occupying a bed. Reasons for this can include: awaiting completion of assessment; awaiting further non-acute NHS care (such as intermediate care or rehabilitation services); awaiting a residential or nursing home placement; awaiting a care package in own home; and awaiting community equipment and adaptations.

About the guideline

• In this guideline, a person with identified social care needs is defined as: someone needing personal care and other practical assistance because of their age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs, or any other similar circumstances.