September 2020: New Hospital Discharge Guidance
The Department of Health and Social Care has issued new guidance in relation to hospital discharge during the COVID-19 pandemic. This chapter will be updated as soon as possible, meanwhile please see Hospital Discharge Service: Policy and Operating Model.
This chapter was added to the APPP in May 2020. It replaces the previous hospital discharge chapter for the duration of the Coronavirus Act 2020 (two years).
- 1. Introduction
- 2. Hospital Discharge Planning
- 3. Continuing Health Care Assessments
- 4. Funding
- 5. Discharge to Assess Model
- 6. Mental Capacity
- 7. What does this mean for Patients?
- 8. Actions for Acute Care Organisations and Staff
- 9. Actions for Hospital Discharge Teams
- 10. Homelessness
- 11. End of Life Care
- 12. Actions for Providers of Community Health Services
- 13. Actions for Councils and Adult Social Care services
- 14. Actions for Clinical Commissioning Groups
- 15. Actions for the Voluntary Sector
- 16. Actions for Care Providers
- 17. Patient Transport
- 18. Equipment and Assistive Technology
- 19. Monitoring and increasing Rehabilitation Capacity
- 20. Finance Support and Funding Flows
- 21. Eligibility
- 22. Reporting and Performance Management
- 23. Additional Resources
- 24. Supporting Guidance
In response to the COVID-19 emergency, the Government has passed the Coronavirus Act 2020 (see Coronavirus Act 2020 chapter). This sets out changes to existing legislation in order to respond to the crisis.
The Hospital Discharge Service Requirement came into effect from Thursday 19th March 2020 and applies to for all NHS trusts, community interest companies and private care providers of acute, community beds and community health services and social care staff in England
During the pandemic demand on hospital beds is likely to be unprecedented. The Hospital Discharge Requirement makes major changes to the previous hospital discharge pathway, as summarised below.
This chapter is a summary of the full guidance. Click on the link to access the full Hospital Discharge Requirements document published by the Department of Health and Social Care.
2. Hospital Discharge Planning
All acute and community hospitals must discharge all patients as soon as they are clinically safe to do, working to the criteria in Annex B, Hospital Discharge Requirement document.
A transfer from the ward to a designated discharge area should happen within one hour of the decision being made. Discharge from the ward should happen as soon after the decision as possible, normally within two hours.
3. Continuing Health Care Assessments
See also Continuing Healthcare (NHS) chapter
In order to expedite the safe discharge of patients from acute hospital beds under EPPR arrangements; to reduce the NHS Continuing Health Care (CHC) assessment burden in and out of hospital settings; and to release clinical and support staff to support the system to manage the COVID-19 outbreak, NHS CHC assessments for individuals in hospital discharge or in the community will not be required until the end of the COVID-19 emergency period.
These arrangements cover:
- the assessment of eligibility for NHS CHC funding;
- individual requests for a review of an eligibility decision (that is local resolution and independent review);
- three and twelve-month reviews of NHS CHC packages of care objectives;
- individuals can still make requests for a review of an eligibility decision however the time frame for a response will be relaxed;
- CCGs will take a proportionate view by undertaking three and twelve-month reviews to ensure that the individual’s care package is meeting their needs and to ensure that any concerns raised are addressed as appropriate;
- commissioning end of life services remains important therefore, and the Fast Track pathway tool can still be used for clinical assessments or other local tools as appropriate. However, to remove decision-making delays, the responsibility to co-ordinate the arrangements for care at home or a hospice bed should be passed to local Community palliative care teams during this period;
- during the COVID-19 emergency period, CCGs will not be held to account on the NHS CHC Assurance Standards nor timeframes for dealing with NHS CHC individual requests for reviews of eligibility decisions.
These measures set out for NHS CHC are only in place for the duration of the COVID19 emergency period.
Local systems need to ensure that they have some method of monitoring actions taken during the COVID-19 emergency measures, for example using the NHS CHC Checklist, so that individuals are assessed correctly once business as usual resumes.
Where social care has been provided free for the emergency period, the expectations of these patients will need to be managed, as some patients may have to contribute or fully fund their care after the emergency period is over.
Clinicians involved in NHS CHC assessment and review are required to assess the specific needs of highly vulnerable individuals and to commission the relevant care. Therefore, it is still important to ensure that care packages are commissioned that meet the needs of these individuals.
The Government has agreed the NHS will fully fund the cost of new or extended out-of-hospital health and social care support packages, referred to in the guidance. This applies to people being discharged from a hospital or who would otherwise be admitted to enable quick and safe discharge.
5. Discharge to Assess Model
The discharge to assess model has four pathways for discharging patients:
- Pathway 0 – Simple Discharge – no input from health/social care, led by acute hospitals;
- Pathway 1 – Support to Recover at Home – with support from health and social care, led by Community Health;
- Pathway 2 – Rehabilitation in Bedded Setting, led by Community Health;
- Pathway 3 – Life-Changing Event – home not an option, led by Community Health.
The Discharge Service needs to operate at least between 8 am-8 pm, seven days a week.
6. Mental Capacity
If a person is suspected to lack the mental capacity to make the decisions about their ongoing care and treatment, a capacity assessment should be carried out before a decision about their discharge is made.
Where the person is assessed to lack the relevant mental capacity and a decision needs to be made, a best interest decision must be made for their ongoing care in line with the usual processes.
If the proposed arrangements amount to a deprivation of liberty, Deprivation of Liberty Safeguards in care homes arrangements and orders from the Court of Protection for community arrangements still apply but should not delay discharge (see Deprivation of Liberty Safeguards chapter).
7. What does this mean for Patients?
Patients will still receive high-quality care from acute and community hospitals, but will not be able to stay in a bed as soon as this is no longer necessary.
7.1 Patient choice
Issues of patient choice and engagement can often delay hospital discharge where there are ongoing social care needs after discharge (particularly if moving to a residential or nursing home).
During the COVID-19 response, there will be a suspension of choice protocols for this particular issue.
The following leaflets have been produced to support the communication of this message.
- Leaflet A – to be shared and explained to all patients on admission to hospital;
- Leaflet B – to be shared and explained to all patients, prior to discharge, this is split into leaflets:
- Leaflet B1 for patients who are being discharged to their usual place of residence;
- Leaflet B2 for patients moving on to further non-acute bedded care.
Giving patients and their families information about the changes to discharge planning is crucial.
On admission, Leaflet A in Annex D, Hospital Discharge Requirements should be given to all patients.
On the day a patient is to be discharged, following discussions with the patient, their family and any other professionals involved in their care – leaflets B1 / B2 in Annex D should be given to patients
A lead professional or multidisciplinary team, as is suitable for the level of care needs, will visit patients at home on the day of discharge or the day after to arrange what support is needed in the home environment and rapidly arrange for that to be put in place. If care support is needed on the day of discharge from the hospital, this will have been arranged, prior to the patient leaving the hospital site, by a care coordinator.
For patients whose needs are too great to return to their own home, a suitable rehabilitation bed or care home will be arranged. During the COVID-19 pandemic, patients will not be able to wait in hospital until their first choice of a care home has a vacancy. This will mean a short spell in an alternative care home and the care coordinators will follow up to ensure patients are able to move as soon as possible to their long term care home.
During the COVID-19 pandemic, all of the above support will be paid for by the NHS, to ensure patients move on from their acute hospital stay as quickly as possible.
8. Actions for Acute Care Organisations and Staff
‘Why not home, why not today?’ Acute providers need to rapidly update their processes and ways of working to deliver the discharge to assess model (see Section 3, Hospital Discharge Requirement).
Social care colleagues should be involved in daily ward reviews. This will help with the early identification of any possible support, placement or housing issues with discharge and allow the MDT to undertake arrangements in good time.
9. Actions for Hospital Discharge Teams
See also Section 5, Discharge to Assess Model
Dedicated staff will need to be arranged to support and manage all patients on pathway 0 – Simple Discharge – no input from health / social care.
This will include:
- coordinating with transport providers;
- local voluntary sector and volunteering groups helping to ensure patients are supported (where needed) actively for the first 48 hours after discharge;
- ‘settle in’ support is provided where needed.
They will also train discharge staff (potentially those who no longer have to undertake CHC assessments) to operate ‘trusted assessments’ for patients admitted into hospital from care homes, so they can return to their care home promptly, and support all care homes with these new discharge arrangements.
See also Homelessness chapter
The hospital clinical and managerial leadership team will ensure planning and discharge for people with no home to go to and that no-one is discharged to the street (See Annex E, Hospital Discharge Requirements for further details on homelessness).
Practices that have been developed in systems to support homeless persons need to be maintained and enhanced to reflect the need to support the needs of those who are without a home and living on the street. It is already known that this group has a high level of mortality, and support needs including mental ill-health and substance misuse which may present a barrier to self-isolation.
NHS trusts have a statutory duty under the Homelessness Reduction Act (2017) to refer people who are homeless or at risk of homelessness to a local housing authority. This statutory duty remains.
To prevent homelessness from delaying discharge, the following should be followed:
- referrals should be made at the earliest opportunity. As soon as it has been identified that a person may be homeless on discharge, this provides more time for the housing authority and other support services to respond. The person must give consent and can choose which authority to be referred to;
- people who are homeless also need to be able to safely self-isolate which also prevents the need for greater care and reduces transmission risks;
- systems should be vigilant in spotting symptoms – using organisations and staff to spot potential COVID-19 positive persons who are homeless and have access to rapid triage to cohort people accordingly;
- local systems need to plan and provide for multiple venues to cohort and care for homeless people who are COVID-19 positive, thereby still managing people in the community where there is a need for spaces to keep people separate with the provision on the street for accommodation, water, food, sanitation.
11. End of Life Care
See also End of Life Care chapter
All patients identified as being in the last days or weeks of their life will be rapidly transferred to the care of community palliative care teams. They will be responsible for coordinating and facilitating rapid discharge to home or a hospice.
This supersedes the current fast track end of life process.
12. Actions for Providers of Community Health Services
Community health services will take overall responsibility for ensuring the effective delivery of the discharge service and for pathways 1, 2 and 3 (see also Section 5, Discharge to Assess Model).
As part of this they should:
- identify an Executive Lead to oversee the implementation and delivery of the discharge to assess model in the acute hospitals in their area. The model should operate at least between 8 am-8 pm 7 days a week;
- release staff from their current roles (see separate Community Health Service prioritisation guidance) to co-ordinate and manage the discharge arrangements for all patients from the community and acute bedded units on pathways 1, 2 and 3;
- have an easily accessible single point of contact which will always accept assessments from staff in the hospital and source the care requested, in conjunction with local authorities;
- deliver enhanced occupational therapy and physiotherapy seven days a week to reduce the length of time a patient needs to remain in a hospital rehabilitation bed;
- use multi-disciplinary teams on the day they are returning home from the hospital, to assess and arrange packages of support for patients on pathways 2 and 3;
- co-ordinate the care for patients discharged on pathways 1-3;
- ensure the provision of equipment to support discharge;
- ensure patients on all three pathways are tracked and followed up to assess for long term needs at the end of the period of recovery;
- maintain the flow of patients from community beds which includes reablement and rehabilitation packages in home settings, to allow the next sets of patients to be discharged from acute care.
13. Actions for Councils and Adult Social Care services
As part of implementing the discharge to assess model, local authorities are asked to:
- agree a single lead local authority or point of contact arrangement for each hospital or Trust, ensuring each acute trust and single local coordinator for local discharge to assess pathways has a single point to approach when coordinating the discharge of all patients, regardless of where that person lives;
- work together and pool staffing to ensure the best use of resources and prioritisation in relation to patients being discharged, respecting appropriate local commissioning routes. During this period, funding will be made available for all patients being discharged and local authorities are enabled by the Care Act (Section 19) to meet urgent needs where they have not completed an assessment and regardless of the person’s ordinary residence;
- coordinate work with local and national voluntary sector organisations to provide services and support to people requiring support around discharge from hospital and subsequent recovery;
- take the lead contracting responsibilities for expanding the capacity in domiciliary care, care homes and reablement services in the local area paid for from the NHS COVID-19 budget.
13.1 Specific responsibilities for Adult Social Care
- identify an executive lead for the leadership and delivery of the Discharge to Assess mode;
- redeploy social work staff from the hospital setting to community settings to support discharged patients. Safeguarding investigations should continue to take place in a hospital setting if necessary;
- ensure there are robust tracking mechanisms to track care placements so that care users do not get lost in the system at a time of very rapid response;
- suspend need for funding panels for hospital discharge during the level 4 incident, with additional funding available to local authorities to cover any increased costs during this period;
- provide social care capacity to work alongside local community health services to provide a single point of contact for hospital staff. Support real-time communication between the hospital and the single point of contact, not just by email;
- provide capacity to review care provision and change if necessary, at an appropriate point;
- work closely with community health providers over the provision of equipment;
- ensure there is a seven-day working week for community social care teams (to be commissioned by local authorities);
- deploy adult social care staff flexibly in order to avoid any immediate bottlenecks in arranging step down care and support in the community and at the same time focusing on maintaining and building capacity in local systems.
14. Actions for Clinical Commissioning Groups
- CCGs should follow the guidance on NHS Continuing Healthcare in line with the detail set out in Annex G, Hospital Discharge Requirement;
- free up staff resources from NHS Continuing Healthcare assessment processes to support the discharge to assess activities and transfer staff to local providers to support these new discharge arrangements;
- arrange for community health end of life teams to take responsibility for any ‘fast track patients’ end of life care patients needing support and step down;
- co-ordinate and lead the rapid implementation of the Capacity Tracker (see Annex F) and NHS mail in care homes and hospices throughout their local area (see Section 8.3, Hospital Discharge Requirement).
15. Actions for the Voluntary Sector
The sector should:
- mobilise quickly and focus on safety and positive experiences for patients on the discharge process, to support people at home including:
- transport home and equipment such as key safes;
- safety checks and essential food shopping;
- daily phone calls and companionship be at the patient’s home to accept any equipment;
- engage with NHS providers (particularly discharge teams) to provide solutions to operational discharge challenges, freeing-up clinical staff for other activities – focusing on the patients on pathway 0;
- NHS volunteers to support hospital discharge
NHS England and Improvement is setting up a new scheme to identify additional volunteers able to support the NHS led by the Royal Voluntary Service using the GoodSAM app as the digital platform.
16. Actions for Care Providers
Care home providers will:
- maintain capacity and identify vacancies that can be used for hospital discharge purposes;
- providers of care homes, in partnership with their local Primary Care Networks and Community Health Provider, should consider how best to support residents, and where already in place, embed the Enhanced Health in Care Home Framework in line with timescales already outlined by NHSEI which have been communicated to primary care providers. This will ensure their residents are better supported (7 days a week) by the NHS;
- to improve communication between health and social care during the COVID19 outbreak, NHSX is speeding-up the roll-out of NHS mail and temporarily waiving the completion of Data Security Protection Toolkit (DSPT) to allow for quicker onboarding. This is in accordance with information governance guidance for COVID-19;
- where Trusted Assessor relationships and arrangements are not in place with Acute providers, rapidly work with the discharge team to implement these rules and processes.
Domiciliary care providers will:
- identify extra capacity to adult social care contract leads, that can be used for hospital discharge purposes or follow on care from reablement services.
17. Patient Transport
Patient Transport Services (PTS) are a critical resource in moving non-emergency patients from one care setting to a more appropriate setting on another site. Demand for PTS will increase through this period, and services will need to be more responsive.
All PTS providers, across the NHS, independent and voluntary sector, will be expected to prioritise the transfer of patients as part of the discharge process in order to maintain flow and maximise patient safety. Organisations should also consider alternative transport options.
This could include:
- local authority owned or contracted vehicles;
- volunteer cars;
- voluntary sector resources;
- taxi services;
- use of patient / relatives’ own car.
18. Equipment and Assistive Technology
The single coordinator will need to ensure there is access to sufficient equipment to support the discharge of people with reablement or rehabilitation needs at home.
As part of this, the local commissioner for NHS and Social Care Equipment must ensure:
- local equipment services (across the NHS and local government) have a sufficient supply of common items of equipment used to support people with reablement or rehabilitation or longer-term care needs;
- access to such equipment can be accessed quickly (the same day where needed) and be available seven days;
- the availability of equipment that can be used to reduce the need for two carers to provide care to individuals, releasing workforce capacity;
- providers have access to adequate stocks of Personal Protective Equipment (see COVID-19 Personal Protective Equipment (PPE) .
- a simple approval process for more complex patients requiring hospital beds, pressure-relieving equipment and hoists. This should be through discussion and verbal approval to order. The current senior clinician approval process and equipment prescription matrices will be stood down;
- regular review and tracking of issued equipment to reduce the over-prescription of equipment. The responsibility for review of equipment once a patient is discharged will sit with the receiving care organisation;
- photographs supplied by family/carers/community staff which will include District Nurses as an alternative to completing access and risk assessment visits for more complex patients. If a visit is required, this will need to be arranged within 4 hours of the decision to discharge the patient;
- discharge tracking information is used to ensure regular restocking of buffer/satellite stores to maintain supply;
- there is a comprehensive range of assistive technology items that can support people to live safely and independently at home with next day access to support if required. This goes significantly beyond falls pendants.
19. Monitoring and increasing Rehabilitation Capacity
After the first phase of discharging existing patients who do not meet the criteria for being in an acute hospital, it will be essential to maintain this approach in any rehabilitation and step down facilitates and broader care-at-home services to avoid creating blockages in the community facilities/services and stop the next sets of patients being discharged from acute care.
19.1 Pathways 1, 2 and 3
- Of those patients discharged to short-term reablement / rehabilitation pathways approximately 35% are likely to require long term care at home or placement in a 24-hour residential or nursing setting.
- It is essential that people on these pathways are tracked and assessed after a period of recovery. Longer-term care or placement must be made available at the right time to ensure that the pathways are not blocked for future patients needing discharge from hospital.
20. Finance Support and Funding Flows
From Thursday 19th March 2020 new or extended or restarted out-of-hospital health and social care support packages will be fully funded by the government This applies to people being discharged from hospital or who would otherwise be admitted to hospital.
There will be a suspension of usual patient funding eligibility criteria while this process is in place.
Commissioners should work with providers of discharge services to ensure that extending existing contracts will be financially sustainable for those providers and consider mitigating actions where there is a risk that they will not be.
Commissioners should plan throughout the period that the enhanced discharge support process is running to ensure appropriate processes are in place for the period following cessation of the enhanced discharge support process. As part of this, planning conversations should be taking place with patients and their families about the possibility that they will need to pay for their care later, as appropriate.
22. Reporting and Performance Management
From Thursday 19 March 2020 current performance standards on Delayed Transfers of Care (DTOC) monthly reported delays will be suspended.
Trusts should continue to report DTOC figures through the usual process, but will not be performance managed on them from this date.
Providers of community rehabilitation beds must start reporting DTOC figures daily to NHS Digital from Monday 23rd March 2020.
NHS providers will be required to report the following during this time:
- bed occupancy in hospitals – via daily sitrep;
- number of patients on daily discharge list;
- number and percentage of patients successfully discharged from discharge list;
- bed availability in community settings, via the Capacity Tracker Tool 11.5 Clinical Commissioning;
- groups will be required to submit the monthly financial spend to NHS England for reimbursement.
23. Additional Resources
To support implementation, NHS England is running webinars to run through the guidance and provide local areas with the opportunity to ask questions.
This will be supported by Frequently Asked Questions which will be regularly updated.
Webinars will be recorded and shared shortly on the Better Care Exchange. please email firstname.lastname@example.org to register.
There will also be virtual support clinic sessions to answer specific local queries.
24. Supporting Guidance
This chapter should be read alongside: