A range of health, social care and other services are involved when adults with care and support needs move into or out of hospital from community or care home settings. Families and carers also play an important part.

Problems can occur if services and support are not integrated. For example, if hospital admissions are not coordinated. This can result in delayed transfers of care, re‑admissions, poor care and avoidable admissions to residential or nursing care. Figures released by NHS England in August 2015 show that on 1 day in June, 5000 people were delayed in hospital.

Hospital discharge problems are reported to occur when people are kept waiting for:

  • assessments of future care and support needs

  • social services or NHS funding

  • further non‑acute NHS care (including intermediate care and rehabilitation services)

  • nursing home placements

  • residential home placements

  • a care package in their own home

  • community equipment and adaptations.

Hospital discharge problems can also occur because:

  • the patient or family refuse the choice of services that have been offered

  • statutory agencies disagree about readiness for discharge or responsibility for ongoing care.

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. This is based on the definition of social care in the Health and Social Care Act 2012 (Section 65).

This guideline considers how person‑centred care and support should be planned and delivered during admission to, and discharge from, hospital. It addresses how services should work together and with the person, their family and carers, to ensure transitions are timely, appropriate and safe.

This guideline has been developed in the context of a complex, rapidly evolving landscape of guidance and legislation, most notably the Care Act 2014.

In line with the Care Act, the guideline covers health and health‑related provision (including housing), and other care and support. It focusses on 'what works', how to fulfil those duties and how to deliver care and support. This guideline does not include transitions involving mental health settings, see NICE's guideline on transitions between inpatient mental health settings and community or care home settings.