Quality statement 4: Transition plan

Quality statement

Adults using intermediate care services discuss and agree a transition plan for when their support ends.

Rationale

An agreed transition plan for when support from the intermediate care service ends will help to ensure that a person's specific needs are met, transfers to other services are successful and the likelihood of hospital admission is reduced. Transition planning should begin as soon as a person starts using the intermediate care service. The transition plan should be reviewed before discharge to reflect any progress made.

Quality measures

Structure

a) Evidence of local referral pathways between intermediate care and statutory, independent and voluntary services.

Data source: Local data collection, for example, a directory of services that includes referral criteria and processes.

b) Evidence of local information about where adults leaving intermediate care can get support.

Data source: Local data collection, for example, a booklet or website with information about local services.

c) Evidence of local processes to ensure that adults using intermediate care services discuss and agree a transition plan for when their support ends.

Data source: Local data collection, for example, service protocol.

Process

a) Proportion of adults starting to use intermediate care services who have a record of a discussion to agree a transition plan for when their support ends.

Numerator – the number in the denominator who have a record of a discussion to agree a transition plan for when their support ends.

Denominator – the number of adults starting to use intermediate care services.

Data source: Local data collection, for example, audit of electronic records.

b) Proportion of adults starting to use intermediate care services who have a documented transition plan for when their support ends.

Numerator – the number in the denominator who have a documented transition plan for when their support ends.

Denominator – the number of adults starting to use intermediate care services.

Data source: Local data collection, for example, audit of electronic records.

c) Proportion of adults discharged from intermediate care whose transition plan for when their support ends was reviewed before discharge.

Numerator – the number in the denominator whose transition plan for when their support ends was reviewed before discharge.

Denominator – the number of adults discharged from intermediate care.

Data source: Local data collection, for example, audit of electronic records.

Outcome

a) Rate of emergency readmissions to hospital within 30 days of discharge from hospital into reablement or rehabilitation services.

Data source: Local data collection, for example, audit of case records. Data on all emergency readmissions within 30 days of discharge from hospital are available from NHS Digital's Clinical Indicators as part of the clinical commissioning group outcomes indicator set – indicator 3.2.

b) Proportion of people who were still at home 91 days after discharge from hospital into reablement or rehabilitation services.

Data source: Local data collection, for example, audit of case records. Data on the proportion of older people (aged 65 and over) who, after a period of reablement or rehabilitation, maintain their independence by remaining or returning to their home or previous residence 91 days after leaving hospital are available from NHS Digital's Clinical Indicators as part of the NHS outcomes framework – indicator 3.6.i.

c) Satisfaction of adults with their transition from intermediate care.

Data source: Local data collection, for example, survey of people discharged from intermediate care.

What the quality statement means for different audiences

Service providers (such as hospitals, community providers, local authorities, care homes, home care agencies and not-for-profit social enterprises ) ensure that processes are in place for adults starting to use intermediate care services, and their family and carers as appropriate, to be involved in developing and agreeing a clear transition plan for when their support ends. Providers ensure that staff are aware of local referral pathways to other statutory, independent and voluntary services, and can access information about local sources of support for adults leaving intermediate care. Providers ensure that the agreed transition plan is documented and shared with the person (and their family and carers as appropriate) and that it is reviewed before discharge to reflect any progress made.

Health and social care practitioners (such as nurses, social workers and allied health professionals) involve adults starting to use intermediate care services, and their family and carers as appropriate, in developing a transition plan for when their support ends. They ensure that the plan is agreed and documented. They provide a copy of the plan in a suitable format to the person (and their family and carers as appropriate) and review the plan before the person is discharged to reflect any progress made.

Commissioners (such as clinical commissioning groups and local authorities) ensure that specifications for intermediate care services include agreeing a clear transition plan with adults starting to use the service (and their family and carers as appropriate), documenting and sharing the plan, and reviewing the plan before discharge. Commissioners ensure that clear referral pathways are in place and there is information about local services that provide support after intermediate care ends.

Adults starting to use intermediate care services are involved in developing and agreeing a plan for any support they may need once their support ends. Their family and carers may also be involved if this is appropriate. The transition plan might include moving to another service, and should include information about other types of support available locally and how to ask for intermediate care in the future. The plan should be clear and easy to understand, and a copy should be given to the person. It should be checked before they are discharged to make sure it is still relevant. The transition plan should help to ensure that they can remain as independent as possible after intermediate care.

Source guidance

Intermediate care including reablement (2017) NICE guideline NG74, recommendation 1.7.2

Definitions of terms used in this quality statement

Intermediate care

A range of integrated services that:

  • promote faster recovery from illness

  • prevent unnecessary acute hospital admissions and premature admissions to long-term care

  • support timely discharge from hospital

  • maximise independent living.

Intermediate care services are usually delivered for no longer than 6 weeks and often for as little as 1 to 2 weeks. Four service models of intermediate care are available:

  • bed-based intermediate care

  • crisis response

  • home-based intermediate care

  • reablement.

[NICE's guideline on intermediate care including reablement, terms used in this guideline section]

Transition plan

The transition plan should be documented, and include:

  • information about how the person can refer themselves back into the intermediate care service if their needs or circumstances change

  • contact details for the service they are being referred to or any services that are restarting (if appropriate)

  • information about potential costs of any ongoing social care services

  • a contingency plan should anything go wrong

  • information about other sources of support available, including support for carers.

[NICE's guideline on intermediate care including reablement, recommendations 1.7.1, 1.7.2 and 1.7.3 and expert opinion]

Equality and diversity considerations

Individual cultural and religious needs should be taken into account when identifying options for ongoing support services following intermediate care.

Discussions about a transition plan for when support from the intermediate care service ends may need to be adapted to meet the needs of people living with cognitive impairment, including dementia, and their family and carers. Healthcare professionals should ensure that the person living with cognitive impairment is supported by a relative or carer or an advocate as appropriate.