This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people's experience of admission to, and discharge from, hospital by better coordination of health and social care services.
The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.
The guideline includes recommendations on:
- person-centred care and communication and information sharing
- before admission to hospital including developing a care plan and explaining what type of care the person might receive
- admission to hospital including the establishment of a hospital-based multi-disciplinary team
- during hospital stay including recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge
- discharge from hospital including the role of the discharge coordinator
- supporting infrastructure
- training and development for people involved in the hospital discharge process.
Who is it for?
Health and social care practitioners
Health and social care providers
Service users and their carers (including people who purchase their own care)
Guideline development process
The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.