Hospital discharge

Working better with hospitals is essential in developing good integrated health and care services, be that to reduce demand for acute services, as well as to ensure people are discharged home in a safe and timely way.


Working better with hospitals is essential in developing good integrated health and care services, be that to reduce demand for acute services, as well as to ensure people are discharged home in a safe and timely way.

We work with a wide range of partners, including the Association of Directors of Adult Social Services, NHS England and Improvement and government departments to develop a range of tools and resources to support better partnership working and improve outcomes for people using hospital or community services.

Our latest national work includes a High Impact Change model for Reducing Preventable Admissions to Hospital and long-term care. Our refreshed High Impact Change model on Managing Transfers of Care builds on lessons learnt from best practice and promotes a new approach to system resilience, moving away from a focus solely on winter pressures to a year-round approach to support timely hospital discharge resulting in quality outcomes for people. We have also collated feedback on good practice and problem solving around the Home First/ Discharge to Assess model including case studies showing how some systems have implemented the High Impact Change models. Our report by Professor John Bolton, Developing a capacity and demand model for out of hospital care shares the learning and developments from seven health and care communities between July 2020 and June 2021 to improve their local arrangements on hospital discharge with a focus on the needs of older people.

We offer a wide range of bespoke support that can assist with:

  • improving the outcomes for people in receiving the right care in the right place at the right time which maximises independence and reduces unnecessary stays in hospital
  • embedding a culture and behaviours in health and care systems which support the principles of Home First
  • improving patient flow and reducing delays
  • ensuring that local systems can access the support they need easily and without unnecessary administrative burden
  • implementing changes, including culture and behaviour changes, and helping to ensure that these are sustainable and sustained.

National resources

NHS England » UEC Recovery 10 Point Action Plan – Implementation guide – This ten-point action plan demonstrates how the whole system will work together to recovery of urgent and emergency services, focusing on the immediate and medium-term actions we can take collectively.

Hospital discharge and community support: policy and operating model – DHSC guidance which Sets out how health and care systems should support the safe and timely discharge of people who no longer need to stay in hospital.

Briefings and publications

Home First / discharge to assess  – A summary from the LGA of what works and how to overcome the challenges of the Home First/ Discharge to Assess model including links to national guidance and examples of local initiatives.

Developing a capacity and demand model for out of hospital care – A report from Professor John Bolton which shares the learning and developments that took place in seven health and care communities between July 2020 and June 2021 to improve their local arrangements on hospital discharge with a focus on the needs of older people.

Implementing a Home First approach to discharge from hospital – LGA and ADASS have produced a short ‘top tips’ guide to safe, timely and appropriate discharge from hospital.

Community health and care discharge and crisis care model: an investment in reablement – Supporting people at home (the ethos of Home First from hospital) and discharge to assess are approaches promoted through the COVID-19 Hospital Discharge Requirements first published in March 2020.

Implementing the Home First Discharge Policy – What you can do now and in the next six months to improve patient flow, care and support after discharge and reduce unnecessary admissions.

People first, manage what matters... –  A report published by Newton Europe - commissioned by the Better Care Support Programme - highlights the challenges health and social care systems are facing to sustainably reduce delayed discharges, and the impact this is having on people’s lives, as well as system finances.

Top tips for implementing a collaborative commissioning approach to Home First
These top tips seek to enable health and care systems to identify what they need to commission to enable people to remain living independently at home, avoiding unnecessary admissions to hospital and enabling a safe and timely discharge home after a hospital stay.

Emerging Practice Guide: implementing the single coordinator – This emerging practice guide provides a range of practical advice, ideas and learning from those in the role, to help systems establish and support the single coordinator role to operate successfully. ​​​​​​

Support including High Impact Change Models and case studies

Reducing preventable admissions to hospital and long-term care – A High Impact Change Model – An LGA tool which aims to support local care, health, and wellbeing partners to work together to prevent, delay or divert the need for acute hospital or long-term bed-based care.

Managing transfers of care – A High Impact Change Model – An LGA tool which promotes a new approach to system resilience, moving away from a focus solely on winter pressures to a year-round approach to support timely hospital discharge.

Managing transfers of care: frequently asked questions

COVID-19 good practice case study: Leicester City – A case study summarising how Leicester City developed its discharge pathways and established a discharge coordination hub supported by the Urgent Community Response and D2A@H services, and enhanced its intelligence and insight to help it manage its response.

COVID-19 good practice case study: Discharge to assess in Warwickshire –   A case study summarising how Warwickshire has maintained, and strengthened, its ‘discharge to assess’ model through the COVID-19 period by remaining aligned to its core principle of maintaining a person centred Home First approach.

Bath: Home First/D2A - A case study summarising how Bath commissioned CURO to provide a Step down service for adults discharged from hospital with no ongoing medical need to remain in hospital, but who are unable to return home immediately.

Resource library

Our full resource library includes a wide range of publications, tools, case studies and webinar recordings, relating to all aspects of System Transformation and Integration.