October 2020: New Hospital Discharge Guidance

This chapter has been revised throughout as a result of revised hospital discharge guidance published by the Department of Health and Social Care.

1. Introduction

The Hospital Discharge Service Policy and Operating Model came into force from 1 September 2020, which sets out the hospital discharge process for NHS trusts, community interest companies, private care providers of NHS commissioned acute, community beds, community health services and social care staff in England.

It replaces the Hospital Discharge Service Requirements published on 19th March 2020. There are a number of key changes.

1.1 Six weeks free care

The Government has provided funding, via the NHS, to  cover the cost of post-discharge recovery, and support services. This will apply to all new and increased care packages for up to a maximum of six weeks following discharge from hospital, rehabilitation or short stay bed. This funding will apply to all those needing support for the first time and increases to existing care packages. Any existing care need that is set out in the care plan or a Care Act assessment will be the responsibility of the local authority, but the cost of any additional care need will be funded by heath in the first six weeks following discharge.

The funding can also be used for urgent community response provided within two hours to prevent an acute admission.

1.2 Continuing Health Care Assessments:

From 1 September 2020, social care needs assessments and NHS Continuing Healthcare (CHC) assessments of eligibility will recommence.

Social care needs assessments and NHS Continuing Healthcare (NHS CHC) assessments of eligibility should be made in a community setting and not take place during the acute hospital inpatient stay. See Continuing Healthcare (NHS) chapter for further information.

1.3 Hospital Discharge Service Policy and Operating Model

This model of hospital discharge introduces significant changes to previous processes and roles.

To support full implementation of the model, a set of Discharge Guidance Action Cards has been developed which  summarise responsibilities and changes in roles for staff within the hospital discharge process.

The model should operate 8am-8pm, seven days a week.

2. Discharge to Assess Model: Four Pathways

This section should be read in conjunction with the Discharge Guidance Action Cards.

The Discharge to Assess Model is based on four pathways for discharging people, as shown below.

Pathway Definition Lead – Actions
Pathway 0: 50% of people Simple discharge, no formal input from health or social care needed once home. Led by acute hospitals

People should only be discharged on pathway 0 if they are considered well enough for self-care upon discharge.

This pathway may include follow ups (for example, the removal of stitches in a clinic setting or at home) but should not include ongoing care.

Pathway 1: 45% of people Support to recover at home; able to return home with support from health and / or social care. Discharge to assess pathways 1-3 require NHS organisations to work closely with adult social care and housing colleagues, the care sector and the voluntary sector.

To ensure that resources are used effectively across the system, acute trusts should ensure that their staff work closely with community health services and local authorities on pathways 1-3.

Information essential to the continued delivery of care and support must be communicated and transferred to the relevant heath and care partners on discharge. This must include, where relevant, the outcome of the last COVID-19 test.

Pathway 2: 4% of people Rehabilitation or short-term care in a 24-hour bed-based setting. Whilst most people will be discharged to their homes, a very small proportion will need and benefit from short or long term residential, nursing home or hospice care as part of pathways 2 and 3.

No-one should be discharged from hospital directly to a care home without the involvement of the local authority. DHSC / PHE policy is that people being discharged from hospital to care homes are tested for COVID-19 in a timely manner ahead of being discharged (as set out in the Coronavirus: Adult Social Care Action Plan), regardless of whether they were residents of the care home previously or not. Where a test result is still awaited, the person will be discharged if the care home states that it is able to safely isolate the patient as outlined in Admission and Care of Residents in a Care Home guidance. If this is not possible then alternative accommodation and care for the remainder of the required isolation period needs to be provided by the local authority, funded by the discharge funding.

Pathway 3: 1% of people Ongoing 24-hour nursing care, often in a bedded setting. Long-term care is likely to be required for these individuals. Whilst most people will be discharged to their homes, a very small proportion will need and benefit from short or long term residential, nursing home or hospice care as part of pathways 2 and 3. No-one should be discharged from hospital directly to a care home without the involvement of the local authority.

Voluntary sector services can also be used to support discharge and prevent further admissions to hospital.

There needs to be clear accountability and escalation mechanisms at each stage of the discharge to assess process in each locality. Hospital Discharge Service Policy and Operating Model, Annex C, Figure 1 describes the discharge to assess process that should be undertaken in acute and community hospitals, and once the person is home.

Health and care systems should ensure effective information sharing, and full and carefully documented assessments of need, to ensure care providers can deliver the care and support people require.

Pathways 1-3  require NHS organisations to work closely with adult social care and housing, the care sector, voluntary sector and community health.

COVID-19 Testing – it is essential to the continued delivery of care and support that information is communicated and transferred to the relevant heath and care partners on discharge. This must include, where relevant, the outcome of the last COVID-19 test. Department of Health and Social Care (DHSC) / Public Health England (PHE) policy is that people being discharged from hospital to care homes are tested for COVID-19 before being discharged (see Coronavirus: Adult Social Care Action Plan, Department for Health and Social Care), regardless of whether they were residents of the care home previously or not. Where a test result is still awaited, the person can still be discharged if the care home is able to safely isolate the patient as outlined in Admission and Care of Residents in a Care Home Guidance. If this is not possible then alternative accommodation and care for the required isolation period needs to be provided by the local authority, funded by the discharge funding.

Commissioners will need to determine which health and care services can best meet the needs of individuals, considering the range of health and care providers offering services in their locality.

3. Discharge to Assess Model: Three Stages

There are three stages to the Hospital Operating Model which are described below. This should be read in conjunction with the Discharge Guidance Action Cards for full detail of changes to roles and processes.

The aim is to support people to maximise their independence and remain in their own home.

Stage One – Ward Based Discharge Planning
Discharge home should be the default pathway.
Review each individual daily and identify people for discharge to leave that day.
Begin discharge planning from the point of hospital admission, including the identification of immediate needs of the individual at home following discharge.
Undertake daily clinically-led reviews of all people at a morning ward round. Any person not meeting the clinical criteria to reside (see Annex A, Hospital Discharge Service Policy and Operating Model) will be deemed suitable for discharge.
Information about the home circumstances for people should have been collected at the point of admission. If further home assessment is required this should be undertaken in good time, coordinated between health and social care and should include equipment and reablement support. Trusted assessment arrangements should be used.
All people who are suitable for discharge will be added to the discharge list.
At least twice daily review of all people in acute beds to agree who no longer needs to be in hospital and can be discharged.
For people being discharged into a care home, supported housing or other temporary accommodation, a COVID-19 test must be carried out prior to admission.
Senior clinical staff should be available to support staff with appropriate risk-management and clinical advice.
Ensure professional and clinical leadership between nursing, pharmacy, medicine and allied health professions for managing decisions and reducing delay. Use these prompts:
  • Does the person require the level of care that they are receiving, or can it be provided in another less intensive setting?
  • What value are we adding for the person balanced against the risks of them being away from home?
  • What do they need next?
  • ‘Why not home, why not today’ for those who have not reached a point where long-term 24-hour care is required.
  • If not home today, then when? Expected date of discharge from an acute bed.
All people who are suitable for discharge will be added to the discharge list. The Single Point of Access (SPA) will allocate to a discharge pathway.
On decision of discharge, the person and their family or carer, and any formal supported housing workers should be involved/informed and receive the relevant leaflet (see Annex B, Hospital Discharge Service Policy and Operating Model).

 

Stage Two – How to Discharge People
On decision of discharge, the person and their family or carer, and any formal supported housing workers should be informed and receive the relevant leaflet (see Annex B, Hospital Discharge Service Policy and Operating Model).
Community health, social care and acute staff need to work together to ensure people are discharged in a safe and timely manner.
For people who are going straight home with no support (pathway 0) the ward staff should arrange discharge.
For those who will require reablement, rehabilitation and/or some care followed by further assessment after recovery, (pathways 1 and 2, for up to six weeks), details of their immediate needs will be given to the single point of access (SPA), a case manager will be allocated and a decision made about which pathway will be used.
All people must be transferred to an allocated discharge area or lounge from their ward as soon as possible, to leave hospital the same day.
Case managers will be responsible, in liaison with ward staff, for ensuring (for all those leaving hospital on pathways 1-3).
Individuals and their families are fully informed of the next steps.
Arrangements to transport people home from hospital are confirmed. This should be via family or carers, voluntary sector, or taxi, and only as a last resort, non-emergency patient transport (NEPTS).
COVID-19 test results are included in documentation that accompanies the person on discharge (where test has taken place).
Hospital discharge teams will arrange dedicated staff to support and manage all people on pathway 0. This will include:
  • make arrangements to transport people home from hospital. This should be via family/carers, voluntary sector, or taxi and, only as a last resort, NEPTS;
  • contact local voluntary sector to help ensure that people are supported for the first 48 hours after discharge;
  • ensure ‘settle in’ support is provided where needed;
  • working with local care home providers, develop trusted assessment arrangements to facilitate the prompt return of residents after a hospital stay.

 

Stage Three – Assessment and Care Planning at Home
Post discharge, the case managers in conjunction with the SPA, will need to work with partners to ensure the staff and infrastructure are available to meet immediate care needs.
The use of personal budgets should be discussed with the individual and their family as an option, if longer term support is needed.
For all those discharged on pathways 1-3, services providing additional care to that in place pre-admission will be at no cost to the individual for a period not exceeding six weeks. It is the case manager’s responsibility to ensure that there is frequent review of the support package and adjustments are made when appropriate. The case manager will liaise with the appropriate professionals to ensure timely assessments for any longer-term care provision and/or associated financial assessments (section 14) or to end support where it is no longer needed.

See also Discharge Guidance Action Cards

4. All Pathways

Important considerations for all pathways are outlined below.

4.1 Mental health

For people with new mental health issues, psychiatric liaison teams should be contacted by case managers in the first instance to review and assess as appropriate.

For people with  pre-existing mental health issues who are known to mental health services, their care coordinator or relevant mental health clinician should be involved in their discharge planning to ensure their mental health needs are considered.

4.2 Mental capacity

The Mental Capacity Act 2005 still applies during this period. DHSC has published emergency guidance for health and social care staff in England and Wales who are caring for or treating a person who lacks the relevant mental capacity during the COVID-19 pandemic (see Deprivation of Liberty Safeguards (DoLS) during the Coronavirus (COVID-19) Pandemic chapter).

If there is a reason to believe a person may lack the relevant mental capacity to make the decisions about their ongoing care and treatment, a capacity assessment should be carried out before decision about their discharge is made.

Where the person is assessed to lack the relevant mental capacity and a decision needs to be made, then there should be a best interest decision 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 and orders from the Court of Protection for community arrangements still apply (see Deprivation of Liberty Safeguards (DoLS) during the Coronavirus (COVID-19) Pandemic chapter).

4.3 End of life care

For people identified as being in the last days or weeks of their life, the single point of access will be responsible for overseeing communication with primary care, community services and, where required, community palliative care services to coordinate and facilitate rapid discharge to home or hospice (see End of Life Care).

4.4 Homelessness

All persons who are homeless or at risk of homelessness on discharge should be referred by acute hospital staff to local authority homelessness/housing options teams, under the requirements of the Homelessness Reduction Act (2017) (see Homelessness chapter). This duty to refer ensures that peoples’ housing needs are considered when they come into contact with public authorities. Further guidance on supporting homeless persons in hospital discharge can be found in the High Impact Change Model for Managing Transfers of Care (Local Government Association).

5. Roles and Responsibilities

The implementation of the Discharge Service Operating Model describes key roles for the implementation of the model:

  • executive lead: health and social care should have an identified executive lead to provide strategic oversight of the discharge to assess process ensuring that there are no delays to discharge and that a ‘home first’ approach is being adopted;
  • single coordinator: a single coordinator should be appointed on behalf of all partners to secure timely discharge on the right The coordinator can be employed by any partner agency  to lead the implementation and delivery of the discharge to assess model in the acute hospitals in their area. This lead role should be undertaken by the most appropriate person for the position, regardless of which organisation they are employed by. Their primary function will be the oversight of coordination of the discharge arrangements for all people from community and acute bedded units on pathways 1, 2 and 3, escalating any relevant issues to the executive lead;
  • case managers: they will ensure all people (irrespective of their address) are discharged safely on time (from all NHS community and acute beds) and that they (or their representative or advocate if they lack capacity), have full information and advice about what is happening. This includes how their needs will be assessed, provision of follow up support as needed and if any charges will be applied to their care and support.

6. What does this Mean for People?

  • Information: People should expect to receive high quality care from acute and community hospitals, including regular sharing of information on the next steps for their care and treatment. Leaflet A, describing these arrangements, is provided in Annex B and should be shared with all people on admission to hospital(see Hospital Discharge Service Policy and Operating Model).
  • Assessment of needs at home: Hospital staff will make clear that discharge will be organised as soon as clinically appropriate and people will not be able to stay in a bed after the point where this is clinically necessary.
  • On the day of discharge: On the day a person is to be discharged, following discussions with the person, their family, and any other professionals involved in their care using leaflets B1/ B2 in Annex B, Hospital Discharge Service Policy and Operating Model ward staff will escort the person to the hospital discharge area where needed.
  • Ongoing care: Care and support will have been organised to meet immediate needs by the case manager, including medication supply, transport home, any volunteer and voluntary sector support and immediate practical measures, such as shopping and turning heating on. For simple discharges (pathway 0) where minimal further support is required, people should expect to be discharged from a discharge area in around two hours. More time may be required for people with more complex care situations that need co-ordinating, though much of the support can be pre-planned during the person’s hospital stay through early discharge planning (see the High Impact Change Model for Managing Transfers of Care, Local Government Association).
  • On day / day after discharge: A lead professional or multidisciplinary team, as is suitable for the level of care and support needs, will visit people at home on the day of discharge or the day after to co-ordinate support needed in the home environment. If care support is needed on the day of discharge from hospital, this will have been arranged prior to the person leaving the hospital site by a case manager.
  • Funding: Additional care and support needs for people on discharge from hospital will be provided free of charge for up to six weeks to allow for post discharge recovery, support services, and further assessment of ongoing care needs and financial eligibility determinations .
  • Admission to care homes: For people whose needs are too great to return to their own home, rehabilitation/short term care bed will arranged by the case manager. For people being discharged to a care home bed (short term or permanently) for the first time, this care will be free to the individual for up to six weeks.
  • COVID-19 testing: DHSC / Public Health England policy is that people being discharged from hospital to care homes are tested for COVID-19 prior to discharge (as set out in the Coronavirus Adult Social Care Action Plan, DHSC), regardless of whether they were residents of the care home previously or not. Where a test result is still awaited, the person will be discharged if the care home states that it is able to safely isolate the patient, as outlined in Admission and Care of Residents in a Care Home guidance. If this is not possible then alternative accommodation and care for the remainder of the required isolation period needs to be provided by the local authority, funded by the discharge funding (see Section 14, Finance and Funding).

7. Actions for Acute Care Organisations and Staff

This model of hospital discharge introduces significant changes to previous processes and roles.

Acute providers need to ensure their processes and ways of working have been fully adapted to deliver the discharge to assess model. See Section 2, Discharge to Assess: Four Pathways and Section 3, Discharge to Assess: Three Stages along with Discharge Guidance Action Cards).

8. Actions for Hospital Discharge Teams

This model of hospital discharge introduces significant changes to previous processes and roles. See Section 3, Discharge to Assess: Three Stages and Discharge Guidance Action Cards.

9. Actions for Hospital Clinical and Managerial Leadership Team

Hospital management teams should:

  • create safe and comfortable discharge spaces for people to be transferred to;
  • maintain timely and high-quality transfer of information to Primary Care and other relevant health and care professionals on all people discharged;
  • use Change 9 within the High Impact Change Model to ensure planning and discharge for people with no home to go to, and that no-one is discharged to the street, or to a night shelter.
  • senior clinical staff should be available to support ward and discharge staff with appropriate risk-management and clinical advice arrangements;
  • ensure COVID-19 testing of all people being discharged from hospital to a care home, in advance of a timely discharge (as set out in the Coronavirus: Adult Social Care Action Plan). Where a test result is still awaited, the person will be discharged if the care home states that it is able to safely isolate the patient as outlined in Admission and Care of Residents in a Care Home Guidance. If this is not possible then alternative accommodation and care for the remainder of the required isolation period needs to be provided by the local authority, funded by the discharge funding;
  • COVID-19 test results should be included in documentation that accompanies the person on discharge;
  • ensure all people identified as being in the last days or weeks of their life are rapidly transferred to the care of community palliative care teams, facilitating prompt discharge to home or a hospice;
  • closely monitor hospital discharge performance data to ensure discharge arrangements are operating effectively and safely across the system, and a high proportion of people on the discharge list achieve a same-day discharge to the most suitable destination for their needs;
  • ensure a live list is available for all agencies to work from and include those suitable for discharge; the number and percentage of people on the list who have left the hospital, and reason of delay for those unable to be discharged in a timely way.

10. Actions for Providers of Community Health Services

This model of hospital discharge introduces significant changes to previous processes and roles. See Discharge Guidance Action Cards.

Providers of community health services will work closely with other system partners to facilitate timely discharge of people, particularly for pathways 1, 2 and 3.

As part of this they should:

  • have an easily accessible single point of contact who will 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 person needs to remain in a hospital or care home rehabilitation bed;
  • monitor the effectiveness of reablement and rehabilitation;
  • use multi-disciplinary teams on the day a person goes home from hospital, to assess and arrange packages of support;
  • ensure provision of equipment to support discharge;
  • ensure people on pathways 1-3 are tracked and followed up to assess for long term needs at the end of the period of recovery;
  • maintain a focus on timely onward transition of care for persons from community beds, including reablement and rehabilitation packages in home settings;
  • community palliative care teams will continue to work with commissioners retaining  responsibility for coordinating and facilitating prompt discharge to home or hospice. End of life care, including palliative care, must continue to be personalised and planned in a holistic way involving the person themselves and their families, social care, community nursing, general practice, occupational therapy, and others.

11. Actions for Local Authorities and Adult Social Care Services

This model of hospital discharge introduces significant changes to previous processes and roles.

See Section 2, Discharge to Assess Model: Four Pathways and Section 3, Discharge to Assess Model: Three Stages also Discharge Guidance Action Cards.

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, who will coordinate all discharges – regardless of where the person lives and will work closely with the single point of access coordinator;
  • work together and pool staffing where appropriate to ensure the best use of resources. Funding will be made available to people with new or additional care needs, 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. Section 19 gives local authority the power to meet needs that fall below the eligibility criteria and provide temporary urgent services before an assessment is carried out (see Appendix 2: Care Act Section 19 for further detail);
  • work with partners to coordinate activity with local and national voluntary sector organisations to provide services and support to people requiring support around discharge from hospital and subsequent recovery.

11.1 Specific responsibilities for Adult Social Care

  • Identify an executive lead for the leadership and delivery of the discharge to assess model. Make provision for Care Act assessments of need, financial assessments and longer-term care planning if necessary.
  • Review the most appropriate setting for social work staff to operate within to support people being discharged. Safeguarding activities should continue to take place in a hospital setting if necessary.
  • 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.
  • Ensure reviews and changes to care provision are completed in line with good practice and legal responsibilities.
  • Organise any needed isolation capacity for people who do not meet the criteria to remain in hospital, in the event that they require to be discharged to a care home but are unable to be isolated in line with the Coronavirus: Adult Social Care Action Plan.
  • Work closely with community health providers and local resilience for a over the provision of equipment, such as personal protective equipment (PPE).
  • Support seven day working for community social care teams (to be commissioned by local authorities).
  • Deploy adult social care staff flexibly to support best outcomes for people. This can include support to avoid any immediate bottlenecks in arranging step down care and support in the community, and at the same time focus on maintaining and building capacity in local systems.

12. Actions for Clinical Commissioning Groups

This model of hospital discharge introduces significant changes to previous processes and roles.

See Section 2, Discharge to Assess Model: Four Pathways, Section 3, Discharge to Assess Model: Three Stages and also Discharge Guidance Action Cards.

CCGs supported by Integrated Care Systems (ICSs) or System Transformation Partnerships (STPs) need to support the coordination of activities set out in this framework. Specifically, they must work in partnership with local authorities to plan and commission sufficient provision to meet the needs of the population based on home first discharge to assess principles.

CCGs should follow the guidance, see Coronavirus: Reintroduction of NHS Continuing Healthcare chapter.

13. Actions for Care Providers

13.1 Care home providers

See also Admission and Care of Residents in a Care Home during COVID-19.

Care home providers should:

  • accept people discharged from hospital when able to do so safely: Care providers should consider whether they are able to meet the prospective clients’ needs, taking into account relevant CQC regulations and provider duties (e.g. ability to isolate, sufficient PPE, and access to staff and resident testing). Ensure isolation of residents transferred from a hospital setting in line with care home isolation and infection prevention guidance and be familiar with alerting mechanisms to local Health Protection Teams in the event of positive COVID-19 test results;
  • maintain capacity and identify vacancies that can be used for hospital discharge purposes, utilising the Capacity Tracker tool to share information with partner organisations;
  • where Trusted Assessment relationships and arrangements are not in place with acute providers, rapidly work with the discharge team to implement these approaches;
  • if providing reablement or rehabilitation, then monitor and share the effectiveness of that service.

13.2 Domiciliary care providers

Domiciliary care providers should:

  • identify capacity to adult social care contract leads, that can be used for hospital discharge purposes or follow on care from reablement services;
  • ensure sufficiency of PPE and COVID-19 testing, the ability to isolate and that assessment and care planning for the future are in place (for example, by ensuring all providers know who to contact to get help, and that robust workforce contingency plans ensure continuity of care);
  • if providing reablement or rehabilitation, then monitor and share the effectiveness of that service.

13.3 Community hospitals

See also Discharge Guidance Action Cards

It is vital that discharges from community hospitals are increased and delays reduced with the same approach and action taken as in acute settings. This includes:

  • a daily clinical review of every person’s plan, focusing on three questions:
    • why not home?
    • what needs to be different to make this possible at home?
    • why not today?
  • the review process should explore why people require rehabilitation in a bedded setting. It is accepted that the majority of people will be medically stable in this setting;
  • all people should have an expected date of discharge (EDD) and be fully involved with their discharge planning. It is essential that expectations are set at the point of transfer or admission;
  • the review should specifically look at whether people can be supported at home. The default assumption will be discharge home today;
  • all actions from the review should be noted and aimed to be completed by the end of the day;
  • keep the Capacity Tracker updated with live status of bed vacancies daily;
  • use and submit the daily data collection of data as described in the ‘COVID-19: new EPRR data collection during COVID-19 incident for community hospital bed providers’ letter, issued on 15 June 2020.

13.4 Short-term placement for people who require 24-hour care and support

  • For people who need a 24-hour care setting, it is essential they are assigned a case manager (social worker, discharge team nurse or CHC co-ordinator) who will review them regularly using the same questions as for community hospitals see above.
  • Discharge should be arranged as soon as possible to their own home and packages of support made available.

13.5 Short term rehabilitation / reablement-at-home review

  • Using a professional supervision / case management model the case manager must review caseloads daily identifying  people who have been on caseloads for an extended period.
  • These people are discussed using the following questions:
    • What is our current aim of support?
    • Have we met this? If not, what is going to change to enable us to meet this aim?
    • Are we best placed to support this need? Is there an alternative?
    • Can we safely discharge this person?
  • Actions from the discussion are recorded and actions followed up daily.

14. Finance and Funding

The Government has agreed to fund, via the NHS, six weeks care post discharge. This will apply to:

  • the cost of post-discharge recovery and support services, such as rehabilitation and reablement (in addition to what was provided prior to admission) for up to a maximum of six weeks to help people return to the quality of life they had prior to their most recent admission;
  • to support urgent community response services for people who would otherwise be admitted into hospital. These will typically provide urgent support within two hours and for a limited time (typically 48 hours) and, if required, transition into other ongoing care and support pathways.

14.1 Discharge Model – Assessment at Home – six week rehabilitation and recovery funding

Eligibility funding assessments for care and health needs should not take place in acute hospital settings. NHSE/I will ensure there is sufficient funding to support CCGs and their local authority partners to commission the enhanced discharge support outlined in the guidance. CCGs are expected to ensure that an appropriate rate is paid for this support working with their local authority commissioners. This agreed rate may need to reflect the actual cost of care, particularly where some care provider capacity being utilised, would previously have been self-funded from the point of hospital discharge.

14.2 Funding after six week recovery and rehabilitation funding

Post-discharge recovery and support services will be funded until the person’s long-term care needs are assessed, or for up to the first six weeks after discharge If the decision is not made about how this care will be funded by this date CCGs will not be able to draw down funding from the discharge support arrangements after the end of the sixth week.

On the rare occasion that a decision is not reached within the six weeks post discharge the parties paying for the care should continue to do so until the care assessments are completed CCGs and local authorities should agree an approach to funding of care from the seventh week.  Where an existing local arrangement is in place to agree who funds care while assessments are taking place, then the local authority and the CCG may choose to continue with this local funding arrangement from week seven rather than following the arrangements below.

In the absence of an existing locally agreed approach for funding from week seven onwards, it is suggested as a default that the following approach is adopted.

The costs are allocated according to what point in the assessment process has been reached by the end of the six weeks of care, as follows:

  • where the NHS CHC or funded nursing care (FNC) assessments are delayed, the CCG remain responsible for paying until NHS CHC / FNC assessment is done;
  • after this, the local authority should pay until the Care Act Assessment is completed, after which normal funding routes will apply.

For people discharged from hospital or assigned a package of short-term care to avoid admission into hospital from 1 September 2020, this funding arrangement will apply, replacing the previous arrangements introduced on 19 March 2020 as part of the COVID-19 Discharge Guidance.

Where a person had a care package prior to admission to hospital and is discharged with a package of short term reablement, this funding will pay for those additional costs (where these are over and above the activity that is ordinarily commissioned by CCGs and local authorities). This would apply regardless of whether or not the person was still being cared for by the same care provider. The local authority is not obliged to pay for any reablement package. The cost of the original care package will still rest with the local authority in funding the person’s initial care and support needs, but it will not be responsible for any new additional care needs that arise from the admission to hospital in the first six weeks. For example, an adult with dementia in a care home suffers an injury from a fall. On discharge the person’s care needs regarding their dementia lie with the local authority; any health and social care needs (i.e. the OT) arising out of fall rest with health for the first six weeks.

14.3 Who pays?

It is essential that, under these arrangements, there is clarity about which CCG is responsible for assessing each person’s needs and paying the relevant organisation for any healthcare services provided to the individual.

14.4 COVID-19 testing

DHSC / PHE policy is that people being discharged from hospital to care homes are tested for COVID-19 in a timely manner ahead of being discharged (as set out in the Coronavirus: Adult Social Care Action Plan) regardless of whether they were residents of the care home previously or not. Where a test result is still awaited, the person will be discharged if the care home states that it is able to safely isolate the patient as outlined in Admission and Care of Residents in a Care Home guidance. If this is not possible then alternative accommodation and care for the remainder of the required isolation period needs to be provided by the local authority, funded by the discharge funding.

14.5 What the six week rehabilitation and recovery funding will not cover

The additional funding will not pay for:

  • long term care needs following completion of a Care Act and / or NHS CHC assessment;
  • restarts of care packages from social care or NHS CHC;
  • pre-existing (planned) local authority or CCG expenditure on discharge services.

15. Reporting and Performance Management

Delayed Transfers of Care (DTOC) monthly reporting was suspended on 19th March 2020. There are no plans to return to this reporting arrangement at present.

However, providers are expected to continue to provide daily reporting through the Strategic Data Collection Service (SDCS). These arrangements identify the numbers of people leaving hospital and where they are discharged to, and the reasons why people continue to remain in hospital.

This information is needed in order to track the effectiveness of this policy. It is likely that revised situation reporting will be implemented in the future.

Appendix 1: Additional Resources and Support

For queries relating to the guidance, please contact england.d2a@nhs.net.

This information should be read alongside  Transition between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Need (NICE)

Discharge to assess also forms part of the High Impact Change Model (HICM) for Hospital Discharge (LGA).

For further detail on discharge to assess, please see the D2A Quick Guide.

Shared guidance to local authority commissioners from the Association of Directors of Adult Social Services (ADASS), the Local Government Association (LGA) and the Care Provider Alliance (CPA).

Coronavirus: Action Plan for Adult Social Care (DHSC) 

Newton Europe publications: Why Not Home, Why Not Today?

People First: Manage What Matters.

Community Health and care discharge and crisis care model: an investment in reablement.

Appendix 2: Care Act Section 19

Subsection one (ss1) where an adult is ordinary resident and has needs which fall below the eligibility threshold; the authority may meet those needs.  A local authority must have carried out a needs assessment before the power arises.

Subsection two (ss2) where a local authority is satisfied on the basis of a needs assessment that the adult has eligible needs but that person is not ordinarily resident in their area, it may still meet those needs

(a) If it has decided not to charge or is unable to charge for a particular type of care; or

(b) In so far there is a charge; one of the three conditions of section 18 are met if:

(I) an adult’s financial resources area assessed as at or below the financial limit

(ii) The adult requests that the local authority meets those needs even if they have to pay for their care in full because their resources are assessed above the financial limit

(iii) The adult lacks mental capacity to arrange care and there is no other person in a position to arrange care and support on their behalf

Subsection three (ss3) the local authority may meet an adult’s urgent needs for care, irrespective of their ordinary residence status. A local authority is not required to have carried out first a needs assessment or made an eligibility decision.

Subsection four (ss4 )a local authority can meet care needs of an adult terminally ill under subsection three.

Appendix 3: Annexes

Hospital Discharge Service Policy and Operating Model

Annexe A: Criteria to Reside – Maintaining good decision making in acute settings

Annexe B: Discharge choice leaflets

Annexe C: Overview of decision making and escalation