Quality statement 3: Coordinated discharge

Quality statement

Adults with social care needs who are in hospital have a named discharge coordinator.

Rationale

Poor coordination related to plans for leaving hospital can result in distress and reduced quality of life for people using services and their carers. Making a single health or social care practitioner responsible for coordinating discharge can help to make the transition smoother (for example, this person can liaise with community services to arrange follow-up care). The discharge coordinator should be involved in discharge planning from admission, and throughout the person's hospital stay.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with social care needs who are in hospital have a named discharge coordinator.

Data source: Local data collection.

Process

Proportion of discharges from hospital of adults with social care needs where there is a named discharge coordinator.

Numerator – the number in the denominator where there is a named discharge coordinator.

Denominator – the number of discharges from hospital of adults with social care needs.

Data source: Local data collection.

Outcome

a) Delayed transfers of care for adults with social care needs.

Data source: Local data collection. National Delayed transfers of care data is published by NHS England.

b) Experience of the discharge process for adults with social care needs.

Data source: Local data collection.

c) Readmission rates for adults with social care needs.

Data source: Local data collection. National data on emergency readmissions within 30 days of discharge from hospital are available from the NHS Digital Indicator Portal as part of the NHS outcomes framework – indicator 3b.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (hospitals) ensure that systems are in place so that adults with social care needs have a named discharge coordinator.

Health and social care practitioners (for example, members of the hospital-based multidisciplinary team) ensure that they involve the discharge coordinator in all decisions about discharge planning for adults with social care needs.

Commissioners (clinical commissioning groups) ensure that they commission services that provide a named discharge coordinator for adults with social care needs.

What the quality statement means for patients and carers

Adults with social care needs who are in hospital are given the name of the person who will be responsible for coordinating their discharge. This person will work with the adult, and their family or carers, to plan their move out of hospital.

Definitions of terms used in this quality statement

Discharge coordinator

A single, named health or social care practitioner responsible for coordinating the person's discharge from hospital. A discharge coordinator may be a designated post or the task may be assigned to a member of the hospital- or community-based multidisciplinary team. They should be chosen according to the person's care and support needs. A named replacement should always cover their absence.

The discharge coordinator should work with the hospital- and community-based multidisciplinary teams and the person receiving care to develop and agree a discharge plan.

The discharge coordinator should be a central point of contact for health and social care practitioners, the person and their family during discharge planning, and should be involved in all decisions about discharge planning.

During discharge planning, the discharge coordinator should share assessments and updates on the person's health status, including medicines information, with both the hospital- and community-based multidisciplinary teams.

They should arrange the details of follow-up care, discuss the need for any specialist equipment and support with community services and, once assessment for discharge is complete, agree the plan for ongoing treatment and support with the community-based multidisciplinary team.

[Adapted from NICE's guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs, recommendations 1.5.1, 1.5.2, 1.5.5, 1.5.14, 1.5.17, 1.5.18 and 1.5.19]

Equality and diversity considerations

Barriers to communication can hinder people's understanding of transitions and how they can be involved in discharge planning. These barriers could include: learning or cognitive difficulties; physical, sight, speech or hearing difficulties; or difficulties with reading, understanding or speaking English. Adjustments should be made to ensure all adults with social care needs can work with the discharge coordinator on plans for their discharge and follow-up care, if they have the capacity to do so.