Introduction

This quality standard covers admissions into, and discharge from, inpatient hospital settings for adults (18 and older) with social care needs. It does not include inpatient mental health settings because a separate quality standard will be produced on this topic.

Social care needs are defined as need for personal care and other practical assistance because of the person's 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).

For more information see the transition between inpatient hospital settings and community or care home settings for adults with social care needs topic overview.

Why this quality standard is needed

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

Problems can occur if services and support are not integrated, resulting in delayed transfers of care, readmissions and poor care. Examples of poor transitions include discharge problems (such as when people are kept waiting for further non-acute NHS care or for their home care package to be finalised), uncoordinated hospital admissions and avoidable admissions to residential or nursing care from hospital.

NHS England's Delayed transfers of care statistics show that, in 2014/15, every day an average of 3.7 adults per 100,000 population had their transfer of care delayed. This is equivalent to over 1,500 delayed transfers a day throughout England. This is up from 3.1 per 100,000 in 2013/14.

Healthwatch England's Safely home: what happens when people leave hospital and care settings? report (2015) highlighted that poor hospital discharge practice leads to unnecessary problems for patients and wasted resources.

In 2012/13 there were more than a million emergency readmissions within 30 days of discharge in England. This cost more than £2.4 billion (Emergency admissions to hospital: managing the demand National Audit Office).

The quality standard is expected to contribute to improvements in the following outcomes:

  • health-related quality of life

  • social care-related quality of life

  • length of hospital stay

  • delayed transfers of care

  • hospital readmissions within 30 days of discharge.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 Adult social care outcomes framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life**

People manage their own support as much as they wish, so they are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily life

Outcome measures

Carers can balance their caring roles and maintain their desired quality of life

1D Carer‑reported quality of life**

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services*

2D The outcomes of short-term services: sequel to service

Placeholder 2E The effectiveness of reablement services

When people develop care needs, the support they receive takes place in the most appropriate setting and enables them to regain their independence

2C Delayed transfers of care from hospital, and those which are attributable to adult social care

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction of carers with social services

Placeholder 3E The effectiveness of integrated care

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

People, including those involved in making decisions on social care, respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual

This information can be taken from the Adult Social Care Survey and used for analysis at the local level

4 Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe**

Outcome measures

Everyone enjoys physical safety and feels secure

People are free from physical and emotional abuse, harassment, neglect and self-harm

People are protected as far as possible from avoidable harm, disease and injuries

People are supported to plan ahead and have the freedom to manage risks the way that they wish

4B The proportion of people who use services who say that those services have made them feel safe and secure

Alignment with NHS outcomes framework and/or Public health outcomes framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 NHS outcomes framework 2016–17

Domain

Overarching indicators and improvement areas

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Reducing time spent in hospital by people with long‑term conditions

2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions

Enhancing quality of life for carers

2.4 Health-related quality of life for carers**

Enhancing quality of life for people with dementia

2.6 i Estimated diagnosis rate for people with dementia*

ii A measure of the effectiveness of post-diagnosis care in sustaining independence and improving quality of life* **

Improving quality of life for people with multiple long-term conditions

2.7 Health-related quality of life for people with three or more long-term conditions**

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3a Emergency admissions for acute conditions that should not usually require hospital admission

3b Emergency readmissions within 30 days of discharge from hospital*

Improvement areas

Helping older people to recover their independence after illness or injury

3.6 i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation service*

ii Proportion offered rehabilitation following discharge from acute or community hospital*

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

ii GP Out-of-hours services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

i Primary care

ii Hospital care

Improvement areas

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Improving the experience of care for people at the end of their lives

4.6 Bereaved carers' views on the quality of care in the last 3 months of life

Improving people's experience of integrated care

4.9 People's experience of integrated care**

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Deaths attributable to problems in healthcare

5b Severe harm attributable to problems in healthcare

Alignment with Adult social care outcomes framework and/or Public health outcomes framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 3 Public health outcomes framework for England 2016–19

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.11 Emergency readmissions within 30 days of discharge from hospital*

4.13 Health-related quality of life for older people

Alignment with Adult social care outcomes framework and/or NHS outcomes framework

* Indicator is shared

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering services relevant to transitions between hospital and the community or a care home for adults with social care needs.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to people using services. Quality statements on these aspects of patient experience are not usually included in topic-specific quality standards. However, recommendations in the development sources for quality standards that affect people's experience of using services and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for transition between inpatient hospital settings and community or care home settings for adults with social care needs specifies that services should be commissioned from, and coordinated across, all relevant agencies. It also specifies they should encompass the whole care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to adults with social care needs moving between hospital and the community or a care home.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality transition between hospital and the community or a care home are listed in related NICE quality standards.

Legislation and policy

This quality standard has been developed in the context of important legislative changes that have a significant impact on people with care and support needs moving between hospital and the community or a care home. The Care Act 2014 establishes new provisions as well as updating existing ones, bringing together relevant policy and guidance affecting people with care and support needs.

NHS England's Seven day services clinical standards set out principles for providing consistent high-quality urgent and emergency care in hospitals. The Emergency Care Improvement Programme's SAFER patient flow bundle aims to improve patient flow through adult inpatient wards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing, caring for and treating adults with social care needs transitioning between hospital and the community or a care home should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with social care needs moving between hospital and the community or a care home. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the decision-making process about investigations, treatment and care. If someone does not have capacity to make decisions, health and social care practitioners should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.