On the 19 March 2020, the Department of Health issued guidance for managing Hospital discharges during the pandemic (the “Discharge Guidance”). It sets out how health and care systems and providers should change their discharging arrangements and the provision of community support during this period of emergency. During this period, Hospitals will need to ensure that it has capacity to support people who have acute healthcare needs. In order to do so effectively, safe and rapid discharge of those people who no longer need to be in a hospital bed will need to be arranged. The new default discharge pathway will be ‘discharge home today’.
The guidance sets out actions that must be taken immediately to ensure that bed capacity is created through faster rates of appropriate discharge from NHS beds. The key emphasis is collaboration and joint working between providers and commissioners to facilitate discharge for patients that are medically well enough to leave hospital.
Discharge to Assess Model
Under the guidance, a discharge to assess model has been introduced which is based on four pathways for discharging patients:
Pathway 0 – 50% of people: simple discharge, no input from health / social care.
Pathway 1 – 45% of people: support to recover at home; able to return home with support from health and/or social care.
Pathway 2 – 4% of people: rehabilitation in a bedded setting.
Pathway 3 – 1% of people: there has been a life changing event. Home is not an option at point of discharge.
Acute hospitals will take the lead on discharging those patients who are on pathway 0. Providers of community health services will take the lead in respect of patients who fall under any of the other pathways.
What is the new process?
There is now a three stage process to follow under the Discharge to Access Model:
A clinically-led review (or equivalent in a community hospital setting) of the patient at an early morning board round is required. This review should involve social care colleagues. Discharge Guidance recommends that the clinicians consider the following:
- Does the person require the level of care that they are receiving, or can it be provided in another setting?
- What value are we adding for the person balanced against the risks of 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?
Patients must be reviewed twice daily to identify patients for discharge for leave that day. All patients who are suitable for discharge will be added to the discharge list and allocated to a discharge pathway. Discharge home should be the default pathway. The discharge list will be managed by the community provider with the lead responsibility.
Once the decision has been made to discharge a patient, community health, social care and acute staff will need to work together (including housing professionals where applicable) to ensure that the patient is discharged on time. The responsibility to coordinate and manage the discharge planning will depend on which pathway the patient is on (acute hospital for pathway 0 and community health services for all other pathways). The patient will be allocated a case manager by the single coordinator. This individual will be responsible for ensuring that the patient and their family are informed of the next steps, transport home is available and they provide support for the patient to settle in to wherever they are discharged to. The patient must be transferred to an allocated discharge lounge within one hour of the decision to discharge (if they have been allocated to pathway 0). Upon arriving in the discharge lounge, discharge from hospital should happen as soon after that as possible, normally within 2 hours.
Once the patient has been discharged, assessment and care planning is carried out at home. The singe coordinator will need to ensure that staff and equipment is available to provide immediate care needs, review and assess for longer-term care packages or end the support where it is no longer required. This should ideally take place on the same day of discharge.
There should be ongoing co-ordination with the Local Authority single point of contact during the discharge process as well as the relevant health commissioner.
Mental Capacity Act
It is important to be aware that duties under the Mental Capacity Act 2005 will still apply during this period. Capacity assessments should therefore be carried out before discharge where a patient is assumed to lack capacity to make decisions about their care and treatment. If the patient does lack capacity, the usual process should follow under the act to ensure that decisions are made in their best interests.
If the discharge arrangements will amount to a Deprivation of Liberty, Deprivation of Liberty Safeguards in the care home arrangements and Orders from the Court of Protection for community arrangements will still apply but this should not delay the discharge process.
What about CHC assessments?
Under section 14 the Coronavirus Act 2020, significant changes have been made to the way in which CHC assessments are carried out during this emergency period. In essence, it provides that CHC assessments can be delayed until the pandemic has ended and therefore there is no requirement to consider CHC prior to hospital discharge. We have produced further guidance on to the changes to CHC.
For those patients who cannot be discharged to their own home and will require nursing or residential care, a suitable rehabilitation bed or care home will be arranged. During the emergency period, patients will not be able to wait in hospital until a care home of their choice becomes available. Instead, once the patient has moved to a care home, a care coordinator will work with the patient to ensure that they are able to move as soon as possible to their long term care home.
How will this be funded?
During this emergency period, the Government has agreed to fully fund the cost of health and social care support packages upon discharge. CCG’s will be expected to ensure that an appropriate market-rate is paid for this support. This will include working with Local Authorities to agree the appropriate approach.
Additional financial support provided to CCG’s and Local Authorities should be collated locally together using existing statutory mechanisms such as Section 75 agreements. Where it is decided that an enhanced supply of out of hospital care and support services will be commissioned by the Local Authority, existing Section75 agreements can be extended or amended to include such services. Likewise, where a CCG is already acting as a lead commissioner for integrated health and care, Section 75 agreements can be varied to allow them to commission social care services.
After a patient has been discharged from Hospital, it is important that they are tracked and assessed to ensure that long-term care and support is put in place as soon as possible to ensure that pathways are not blocked for future patients. This is particularly essential for those patients in a community hospital, who require 24-hour care setting or require rehabilitation.
What does this mean in practice?
Acute Care Organisations and Staff
- Social care workers should be involved in the daily reviews to help with the early identification of any possible support or issues with discharge and allow the multi-disciplinary teams to make arrangements as soon as possible.
- Hospital discharge teams will need to arrange dedicated staff to support those patients on pathway 0.
- There will be a need to ensure that there is enough comfortable and safe space in the discharge lounge to cater for the increased number of discharges.
- Senior clinical staff to be available to support ward and discharge staff to take appropriate risk-taking and clinical advice arrangements.
- There will be a need to ensure that all patients identified as being in the last days / weeks of their life are transferred to the care of community palliative care teams who will be responsible for co-ordinating and facilitating rapid discharge to home or a hospice.
- Where applicable, COVID-19 test results are to be included in documentation that accompanies the person on discharge.
Providers of community health services
- Providers will need to identify an executive lead to oversee the discharge to assess model process in the acute hospitals in their area.
- They will be required to release staff from their current roles to co-ordinate and manage the discharge arrangements for all patients from community and acute bedded units under pathways 1 - 3.
- They will need to deliver enhanced occupational therapy and physiotherapy to reduce the length of time a patient needs to remain in a hospital rehabilitation bed.
- Ensure that multi-disciplinary teams are used on the day of discharge home from hospital to assess and arrange packages of support for those patients under pathway 2 and 3.
- Co-ordinate the care for patients discharged on pathways 1 - 3
- Ensure provision of equipment to support discharge.
- Ensure patients on pathways 1 - 3 are tracked and followed up to assess for long terms needs at the end of period of recovery.
- Maintain the flow of patients from community beds to allow the next set of patients to be discharged from acute care.
Councils and Adult Social Care services
- Local authorities will need to agree a single lead / point of contact for each Hospital or Trust to approach when coordinating discharge regardless of where that patient lives.
- Pooling staff together to prioritise patient discharge.
- Coordinate work with voluntary sector organisations to provide services and support to patients being discharged from Hospital.
- Lead contracting responsibilities for expanding the capacity in domiciliary care, care homes and reablement services in the local area paid for from the NHS.
- Free up staff resource from NHS CHC assessment processes to support the discharge to assess process.
- 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 and NHS mail in care homes and hospices.
- Maintain capacity and identify vacancies.
- Adopt the Capacity Tracker during the emergency period to ensure that vacancy information is made available to NHS and social care colleagues.
- Implement NHS mail to maximise communication between NHS and social care colleagues.
It is understood that many areas have local access to discharge pathways that may need to be extended in terms of scope and scale in order to facilitate rapid discharge in accordance with the Discharge Guidance. Urgent discussions will therefore need to take place at commissioner level to implement such processes.
We will be issuing separate guidance notes on:
- Coronavirus Act 2020 – Changes to Local Authority Duties under the Care Act 2014
- Coronavirus Act 2020 – NHS Continuing Healthcare and Funded Nursing Care
For specific advice please get in touch with:
For further support and advice relating to the impact of COVID-19, please view our COVID-19 Advisory Service Page.