Quality statement 4: Discharge plans
Adults with social care needs are given a copy of their agreed discharge plan before leaving hospital.
The discharge plan is an important part of a coordinated discharge process. To ensure adults with social care needs have a positive experience of this process, they need to understand and agree their own discharge plan, if they have the capacity to do so. If the person chooses to share the plan with everyone involved with their ongoing care and support this can lead to successful transfers and reduce the chance of hospital readmission.
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Evidence of local arrangements to ensure that adults with social care needs are given a copy of their agreed discharge plan before leaving hospital.
Data source: Local data collection.
Proportion of discharges from hospital of adults with social care needs that include the person being given a copy of their agreed discharge plan before leaving hospital.
Numerator – the number in the denominator where the person is given a copy of their agreed discharge plan before leaving hospital.
Denominator – the number of discharges from hospital of adults with social care needs.
Data source: Local data collection. The Care Quality Commission's Adult Inpatient Survey gives national data.
a) 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.
b) The experience of discharge from hospital for adults with social care needs.
Data source: Local data collection.
Service providers (hospitals) ensure that systems are in place for adults with social care needs to be given a copy of their agreed discharge plan before they leave hospital.
Health and social care practitioners (discharge coordinators and members of the hospital- and community-based multidisciplinary teams) ensure that they give a copy of the agreed discharge plan to adults with social care needs before they leave hospital.
Commissioners (clinical commissioning groups) ensure that they commission services in which adults with social care needs are given a copy of their agreed discharge plan before leaving hospital. This supports NHS England's Seven day services clinical standards, standard 1.
Adults with social care needs are given a copy of the plan for their move out of hospital before they leave. The plan should be easy for them to read and understand, and people giving them this information should also offer to explain it to them.
A document that describes the coordination of care and support for discharge from hospital. It is in addition to a discharge summary that is sent to a person's GP on discharge. It is a working document for the multidisciplinary teams. A discharge plan should take account of the person's social and emotional wellbeing, as well as the practicalities of daily living. It should include:
details about the person's condition
contact information after discharge
arrangements for continuing social care support
arrangements for continuing health support
details of other useful community and voluntary services.
The discharge plan should also include a complete, accurate list of their medicines, including any changes made to medicines during their hospital stay. This includes information about when to take the medicine, correct dosage and an explanation of what it is for.
The discharge plan should be shared with the adult and all those involved in their ongoing care and support, if the adult agrees. All the information, including information about medicines, should be in a format that is easy for the person to understand. [Adapted from NICE's guidelines on transition between inpatient hospital settings and community or care home settings for adults with social care needs (glossary, recommendations 1.1.2, 1.1.6, 1.5.15 and 1.5.16) and medicines optimisation (recommendation 1.2.4), and expert opinion]
The discharge plan should be provided in a format that suits people's needs and preferences and meets the requirements set out in NHS England's Accessible Information Standard.
Barriers to communication can hinder people's understanding of transitions and how they can be involved in discharge planning. For example, these barriers can include: learning or cognitive difficulties; physical, sight, speech or hearing difficulties; or difficulties with reading, understanding or speaking English.
Adjustments should be made to overcome these barriers and ensure all adults with social care needs can be involved in making decisions about their discharge and follow-up care, if they have the capacity to do so. Support for people with communication difficulties may include access to advocacy services.