Managing transfers of care – A High Impact Change Model: Changes 1-10

The Managing Transfers of Care HICM is designed to support local system partners to improve health and wellbeing, minimise unnecessary hospital stays and encourage them to consider new interventions. It is not a performance management tool but a vehicle for self-improvement.


Introduction

Each Change has a maturity matrix which allows systems to self-reflect on where they are at and create an improvement plan to address areas of development. For further information on the background of the tool, and the purpose and principles which underpin it, please visit the Managing transfers of care - a High Impact Change Model.

Change 1: Early discharge planning

In elective care, planning for discharge should begin before admission. In emergency/unscheduled care, a joint crisis response for people living at home and in care settings can prevent unnecessary admission. However once admitted, an expected date of discharge should be set as soon as possible.

Making it Real’- I/We statement
When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place before change happens.
We support people to plan for important life changes, so they can have enough time to make informed decisions about their future."

Tips for success

  • Ensure the MDT sets a proposed date of discharge prior to admission for elective admissions and within two days of an emergency admission.
  • Early identification of people who will need support on discharge, and referral to the care transfer hub (see Change 3) allows staff to identify the appropriate pathway and set up appropriate packages in a safe and timely way and achieve a same day discharge. This is particularly important where there are concerns about mental capacity, safeguarding or other complexities.
  • Ensure the individual and their family and carers are involved and central in discussions about discharge and that this occurs as early as possible. Encourage and support them to take responsibility in discharge planning. To enable this, from the start the person should be asked who they wish to be involved or informed in discharge discussions and decisions. 
  • Where appropriate, ensure that referrals to independent advocacy services are made as soon as discharge planning begins. Where there is a legal duty, ensure referrals to Independent Mental Capacity Advocate are made as soon as the need is identified.
  • If there are reasons to believe a person may lack mental capacity, a capacity assessment should be carried out to as part of the discharge planning process. It is important to identify this as early as possible during the discharge planning process. Any capacity concerns should be considered alongside other support needed during discharge planning.
  • Ensure that there is early identification of homelessness and referral to appropriate services by ward staff on duty.
  • Draw up a simple but practical discharge plan and ensure practical considerations are accounted for (e.g. keys, clothes, heating). 
  • Identify potential barriers to discharge and review these on a daily basis (e.g. the individual is homeless or their home will be unsuitable to return to meaning they need a move to more suitable short-stay or permanent accommodation, or aids and adaptations to their home).
  • Ensure there is clear ownership of actions and all agencies required for resolution are involved. Staff should have a strong understanding of procedures and escalation processes.
  • Ensure all staff are aware they all have a role in discharge planning.
  • Ensure that there is case management and patient tracking at every stage of the discharge planning process. This will be enabled by effective processes and digital tools. It is crucial that the care transfer hub has accurate and live visibility of patients and their next steps, as well as system wide capacity.
  • Although some might consider waiting to start discharge planning for those with dementia, it is key to start planning as early as possible, especially ensuring information about their care preferences and needs has been gathered and is available at the bedside.

Examples of emerging and developing practice

Newcastle Gateshead: Bringing care homes from the periphery - Introduction of a ‘transfer of care bag’, helping to improve communication between hospital and care home teams when residents moved between both settings, and raising the profile of older people living with frailty and very complex needs in care homes.

Maturity levels

High Impact Change Model - Change 1 maturity level

Supporting materials

Change 2: Proactive demand and capacity planning

Use data from across the system to understand what short-term services people are likely to need following discharge from hospital and work with local providers to commission and develop services that best meet those projected needs, working across health, social care and the voluntary sector.

‘Making it Real’- I/We statement
If I need a new or additional package of care and support when I leave hospital, I get the care and support that best meets my individual needs.
We work in partnership to make sure that we have the right services in the right place at the right time to meet people’s short-term needs when they leave 

Tips for success

  • Establish a digital platform to provide real-time information about people and capacity across the system. You might develop a bespoke platform for your area or adopt an existing system. Refer to ‘Enabler 2: Digital and Data’ for more information on how to develop platforms and leverage data.
  • Use data analysis to understand system trends, to lead medium and long-term strategy, and to anticipate service demand across health and social care.
  • Create plans to manage variance in system demand on a seasonal, weekly and daily basis, and to respond to unanticipated demand. This may not mean increasing capacity, but instead arranging staff rotas etc. to put resources in the best place/time.
  • While councils remain the lead commissioners and retain their Care Act duties in relation to assessment and care planning, safeguarding and market management, a joint approach is key to developing post-COVID step-down facilities, integrated community and primary health and social care support and work with the VCSE sector.
  • Daily ward and board rounds – virtual or face to face are key to managing flow to ensure people are on track to go home in a safe and timely way.
  • Identify key system blockages and take action to resolve them. This may involve other high impact changes, such as Home First D2A, depending on your system’s needs.
  • Utilise ‘Red and Green Bed Days’ system help understand flow through the hospital by identifying wasted time in a person’s journey in both acute and community ward settings.
  • Give frontline staff the information they need to understand service capacity and to make the best decisions for individuals.
  • Make plans for sharing relevant information easily and in a timely manner among partners. This will require an understanding of what information is useful to which system partners, and consideration of data governance.
  • The Better Care Fund (BCF) plans provide a picture at local system level of planned capacity to meet demand. Ensure that these are part of the demand and capacity planning process, and remember that all systems will be expected to refresh their BCF demand and capacity plans annually.
  • The local system must also consider which modelling approach to use when carrying out demand and capacity planning, and should ensure there is high level understanding and agreement on the approach. The urgent and emergency care (UEC) recovery plan support module on ‘Understanding Intermediate Care through Demand and Capacity planning’ outlines three types of modelling, please refer to it for more information.
  • When carrying out the modelling activity, local data should be used as a first port of call, but there are also nationally available data sources that will be useful in developing an understanding of forecasts. These data sets can be found in the data sources part of this page.
  • There needs to be careful consideration of the dementia strategy for the local system. Any dementia strategy must involve the development and commissioning of specialist bedded care places that are able to support older people who have more challenging symptoms such as a higher level of confusion, aggressive behaviours, or levels of delirium.
  • In addition to particular consideration for intermediate services, it is also important to ensure that local commissioning plans include provision of specialised support that meets the local population’s needs. This can include people with ongoing mental health needs, a drug or alcohol dependence, a learning disability, dementia, those in the last few months of life, and a range of other factors and conditions which may require specialised support in the community.
  • Remember to explore efficiency improvements in intermediate services’ capacity, including exploring how to safely implement single handed care, having control over length of stay in services, and opportunities in shift rotas.
  • It is helpful to remember that funding to support discharge can be pooled across health and social care, and local agreements should be in place to minimise discharge delays.
  • In ‘cross border’ situations it is important to follow ‘Who Pays?’ guidance. If there are issues that arise on a regular basis, the local authority and ICB should develop agreements to ensure that any decisions about the joint funding of care can be made quickly.

Examples of emerging and developing practice

  • Kent: Use of SHREWD - Use of a daily reporting system to view capacity and flow within Home First/ Discharge to Assess pathway.
  • Central Bedfordshire: Hospital Discharge Service- Person Tracker - To support the working of the co-located discharge teams, a ‘person tracker’ was developed, which has enabled the council to provide a single point of monitoring for its residents’ admission, hospital stay and discharge data.
  • Southampton: Hospital flow and bed management - Implemented an electronic system as a more effective way of managing complex discharges, which includes a user dashboard designed to provide “at a glance” status reports.

Maturity levels

High Impact Change Model - Change 2 maturity levels 

Supporting materials

Change 3: Care transfer hubs and multi-disciplinary working to coordinate discharge

Effective discharge and positive outcomes for people are achieved through coordinated discharge planning based on joint assessment processes and protocols, shared and agreed responsibilities, and good conversations with, and information for, people and families. Working together with the individual at the centre results in a more timely, safer discharge to the right place for them.

A care transfer hub is a focal point for coordinating discharge for people with new or increased needs who require post-discharge health and/or social care and support (in other words, those on discharge pathways one, two and three). Care transfer hubs delivering a Home First and D2A approach have been shown as an effective model for managing discharges from hospital.

‘Making it Real’- I/We statement
I have care and support that is coordinated and everyone works well together and with me.
We work with people as equal partners and combine our respective knowledge and experience to support joint decision-making." 

Top tips for success
 

Care transfer hubs

  • A care transfer hub is a focal point for coordinating discharge for people with new or increased needs who require post-discharge health and/or social care and support (in other words, those on discharge pathways one, two and three). All complex discharges into intermediate care will therefore be managed by the hub.
  • Care transfer hubs will be either directly involved in or aligned to each of the 10 high impact changes outlined in this document and therefore it is vital to ensure the development of care transfer hub capability is embedded in wider improvement activities for flow, hospital discharge and the development of intermediate care services. This should include ensuring aligned wider governance structures, with a named Senior Responsible Officer (SRO) for the care transfer hub function that supports clear, formal, escalation routes.
  • Details of the functions and structures of a mature care transfer hub can be found in the Good Practice Guide for Transfer of Care Hubs, developed by the Local Government Association (LGA) and national partners in 2022.
  • In addition, national partners have engaged with high-performing care transfer hubs to develop a set of nine priorities for the development of care transfer hubs. Despite a range of different models of care transfer hubs being in operation across England, these areas of focus have been identified as fundamental elements to all mature hubs.

General principles of multi-disciplinary working
 

In addition to care transfer hubs, it is important to consider multi-disciplinary working and principles in other environments such as multi-disciplinary teams (MDTs) on the wards and in intermediate care provisions:

  • Working together with the individual at the centre results in a more timely, safer discharge to the right place and improved outcome. Consideration of people’s mental capacity, their rights to continuing healthcare and their ongoing Care Act support needs are all better discussed outside hospital in a setting which maximises their opportunity for independence and reablement.
  • In ward MDTs, ensure social care and representatives of the care transfer hub other discharge support services are involved in board rounds.
  • Ensure the individual is treated as an equal partner in the co-planning of care. Provide accurate information and advice to them and their families and carers about their options and the risks involved, dispelling fears and working together to achieve the right outcome.
  • Train your MDT to take a strengths-based, person-centric approach to coordinate care and support around the individual. Use continuous feedback and evaluation to improve the experience for staff and people accessing care.
  • Make sure people have a named point of contact within the team and know who to talk to about planning their discharge.
  • Tackle barriers to smooth and effective MDT working; ensure processes are clear and well-understood, and take measures to reduce funding disputes or confusion about responsibilities.
  • Health and social care professionals should follow commitments to reducing health disparities and inequalities. To achieve this, enable professionals to understand relevant issues that have protected characteristics. In addition, ensure that any mental capacity and safeguarding concerns have been considered alongside other support required.
     

Examples of emerging and developing practice:
 

  • Durham: Multi-disciplinary discharge teams - Teams Around Patients (TAPs) is a virtual model of integrated care delivery, which uses a multi-disciplinary working platform involving social workers, nursing and allied health professionals. 
  • Lincolnshire: Hospital avoidance response team - A service delivered by members of the Lincolnshire Independent Living Partnership, which takes referrals from secondary care discharge hubs, A&E in-reach teams, the ambulance service, primary care and community health providers, to help either prevent an avoidable A&E attendance or admission, or speed up discharge from secondary care.
  • Luton and Dunstable: Integrated discharge hub - Co-location of the team which has regular multi-disciplinary sessions to track and discuss complex patients and their length of stay.
  • Additional case study to be added

Maturity levels

High Impact Change Model - Change 3 maturity level

Supporting materials


Social Care Institute for Excellent resource for MDT working
National Institute for Health and Care Excellence guidelines on transfers of care, including how the multi-disciplinary team should work
Health Education England framework for care navigation
Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge

Change 4: Home First

This means always prioritising and, if at all possible, supporting someone to return to their usual place of residence before considering other options, because home is best. 

‘Making it Real’- I/We statement
I can live the life I want and do the things that are important to me as independently as possible.
We talk with people to find out what matters most to them, their strengths and what they want to achieve and build these into their personalised care and support plans."

Tips for success
 

  • Establish system-wide principles between partners and develop a single narrative across the system about supporting people home as a default option. Concentrate on costs to the system, not provider versus commissioner or health versus social care costs.
  • Ensure discharge pathways are set up so home first is the favoured option.
  • A home first approach and understanding that home is best also involves system-wide work to support people to remain at home: consider how multi-disciplinary teams and community/home care services can be developed to prevent escalation of need and avoid unnecessary hospital admissions or readmissions.
  • Work with consultants and therapists to build confidence and overcome risk aversion to discharge, using positive stories to achieve a hearts-and-minds culture change.
  • Make sure to engage the person, family and carers at the appropriate time, taking into account their preference. As part of this engagement, ensure that there is information captured on the person’s home situation including the support they currently receive.
  • Ensure there is an effective multidisciplinary care transfer hub making the decision regarding the discharge pathway for each individual, working with ward stuff. To ensure these staff can see the person’s maximum independence potential.
  • When organising your care transfer hub, take careful consideration on the make-up of the team, making sure to include therapists and colleagues that have good knowledge of available community services and their criteria. For more information on care transfer hubs, look at ‘Change 3 – Care transfer hubs and multi-disciplinary working (MDTs) to coordinate discharge.
  • It is crucial to capture data on the proportion of people discharged to each pathway. This information should be used to inform services to ensure an appropriate proportion of people are being discharged to each pathway, recognising that this proportion will be different depending on the case mix. It is helpful to have a view of outcomes post discharge to ensure that the optimal discharge decision is made. This will contribute to effective demand and capacity planning.  Refer to ‘Change 2: Proactive demand and capacity planning' for more information. 
  • It can be helpful to organise periodic reviews of people’s outcomes to capture best practice and understand if there were opportunities missed that could have led to more independent outcomes, which again will impact demand and capacity planning.
  • Remember to ensure that health and social care professionals follow ongoing commitments to reduce health disparities and inequalities.  This means that when making discharge decisions, it is important to understand challenges relevant for people with protected characteristics.
  • When a person has capacity, they should be supported to manage any risks by health and social care services. When there is reason to believe the person may lack mental capacity about discharge, a capacity assessment should be carried out as part of discharge planning process, with any mental capacity and safeguarding concerns being considered as part of the optimal discharge pathway decisions.
  • Consider how the use of assistive technology including safety gadgets, tracking devices, alarms, and cameras can help ensure a person is safe and has good engagement with local communities, this can be particularly important for people with dementia. Ensure the need is identified and communicated to appropriate services as early as possible.
  • Consider that people may require specialised support to have their needs met. This is particularly the case for people with ongoing mental health needs, a drug or alcohol dependence, a learning disability, dementia, those in the last few months of life, and a range of other factors and conditions may require specialised support in the community.
  • For those at the end of life, it is important that professionals making the discharge decision are aware of Special Rules for End of Life and support applications for those who are eligible. Professionals should utilise the NHS CHC Fast-Track Pathway tool, whilst also considering other key requirements.
  • The capacity tracker and other data sources are helpful tools to identify what local services are available to support people.
     

Examples of emerging and developing practice
 

  • Bath: Home first/D2A - A step down service (which uses apartments), and can be commissioned by any hospital clinician or health care professional involved in the discharge process.
  • Medway: Home First - An approach and ethos which has sought to achieve Medway Health and Social Care Partners’ pledge to: minimise patients’ acute hospital length of stay; maximise independence through enablement; support care at home or closer to home; and make no decision about long term care in an acute setting.

Maturity levels
 

High Impact Change Model - Change 4 maturity levels 

Supporting materials

Change 5: Discharge to assess and effective intermediate care

The decision about a person’s long-term care should not be made in an acute hospital, but at home or in an intermediate service after a period of rehabilitation and recovery, either at home or in a bedded facility if appropriate.

Making it Real’- I/We statement
I am able to recover and be rehabilitated in the best setting for me to allow me to have the most independent life possible. We only assess people’s need for long term support after a period of recovery and rehabilitation."

Tips for success
 

Discharge to assess:
 

  • The decision about future care should not be made in an acute hospital, but in the person’s own home or intermediate setting after a period of rehabilitation, reablement and recovery and be the persons own decision, wherever possible, not the decision of family, clinicians or other professionals – people need to be informed and empowered to choose, whatever their age, disability or circumstance.
  • Make sure these services will work for everyone: have a single point of access, including for people who fund their own care, people who need only low-level support, people who appear to meet the Care Act eligibility threshold and people who don’t, and people with ongoing care needs.
  • Track people to see where they are six months after discharge to monitor progress and impact of home first initiatives. You should expect to see a reduction in support for those with ongoing support needs. Monitor services as to their quality and effectiveness in terms of reablement and do not use services that will not provide that information or whose results are poor.
    Ensure Continuing Health Care (CHC) and other assessments of long-term need are made after a period of rehabilitation, reablement and recovery, during which a person’s support requirements may change.
  • In exceptional cases, there will be people discharged from hospital that would not benefit from discharge to assess and intermediate services in their current format. It is important to identify those people and plan for the right support for them.
  • Consider using trusted assessment to provide speedy access for discharge to assess pathways or other discharge support services. To understand more about trusted assessment, look in ‘Change 6- Trusted assessment’

Intermediate Care Services:
 

  • Start with home based intermediate services, such as reablement (rather than bed-based options) both in terms of service development and choice. We have seen the real benefit of caring for people in their own homes with domiciliary care support or PAs arranged via a personal budget.
  • Remember there is strong evidence that therapy-led services achieve the best results. Consider merging reablement and rehabilitation services with voluntary sector support.
  • To have a good home first support service you need it to be fully integrated i.e. NHS, the local authority, and VCSE and independent sector as well as having support structures of families, carers or advocates.
  • Support the workforce to be able to set SMART (Specific, Measurable, Achievable, Relevant, Timely) goals with every person in intermediate care and a target level of support. Progress against these targets should be regularly reviewed to ensure that people are reaching the target level of independence.
  • Regular MDT discussions should ensure that people's independence levels and length of stay in services are a continuous focus.
  • For intermediate care services to be most effective it is important to ensure appropriate capacity and demand planning for these services. Look in ‘Change 2: Proactive demand and capacity planning' for more information on this. So that demand and capacity planning can be as accurate as possible, it is important to share accurate data with those carrying out the planning activity.
  • As part of capacity planning, ensure there is the right workforce to support the service. In particular, it is essential for there to be sufficient therapy workforce and support workers to lead on the reablement and rehabilitation of people.
  • For the most effective services, it is important that sufficient, relevant and accurate information is provided on discharge. Review processes for capturing and sharing information to ensure efficient and seamless. Consider how to share good quality information with families and carers (refer to change 5: engagement and choice for more detailed information).
  • There are opportunities that should be explored locally to maximise capacity in existing services without relying on additional resource. These should feed into demand and capacity planning.  Refer to ‘Change 2: Proactive demand and capacity planning’ for more information. Opportunities include managing length of stay through clear action tracking, discussions in MDTs and identifying what blockers may delay discharge from service; and understanding if there are any shifts within the services rota that are preventing the services supporting more people and if so, whether there are opportunities to balance shift rotas. In home-based services, there is the further opportunity to be tactical on when people receive their support from the service.
  • In home-based services, exploring opportunities around training, equipment or assistive technology so that we are optimising manual handling so where people can be safely managed with a single-handed approach they are
  • For people with dementia, it is key that the workforce supporting them has received appropriate training in how to support people with dementia.
  • Intermediate care services should also focus on helping those with a diagnosis of dementia and their carers to learn how to best live with and manage their way safely with the condition.
  • Alongside general intermediate services, it is helpful to consider other specialist support that can support the reablement or recovery of a person. This is particularly relevant to people with ongoing mental health needs, a drug or alcohol dependence, a learning disability, dementia, those in the last few months of life, and a range of other factors and conditions may require specialised support in the community.
  • Where required, the transition from intermediate support to long-term support should be seamless both from the person and family’s perspective, but also from a professional perspective. To enable this, it is best practice for any assessments of long-term support to be initiated at the start of a person’s recovery journey but not finalised until professionals are able to make an accurate assessment.
  • To avoid delays to discharge due to funding disputes between health and social care, follow ‘Who Pays?’ guidance or any locally developed agreements for regular situations.
  • Regularly review and evaluate intermediate care to ensure short term beds are not becoming permanent. Take measures to ensure the focus here is on rehabilitation, reablement and recovery, not on getting people out of acute hospital beds.

Examples of emerging and developing practice:
 

  • North Staffordshire: Track and triage - Replacing the assessment functions on the acute site, it tracks patients from entry-to-end of D2A, with a ‘pull’ function once the patient is judged medically fit for discharge.
  • Bath: Home first/D2A - A step down service (which uses apartments), and can be commissioned by any hospital clinician or health care professional involved in the discharge process. 
  • Tower Hamlets: Admission avoidance and discharge service - Consists of rapid response in the community; an admission avoidance team; in-reach nurses and admission avoidance and discharge service (AADS) screeners; and an intermediate care team using a D2A model and offering up to six weeks intensive rehabilitation in the community.

Maturity levels

High Impact Change Model - Change 5 maturity levels

Supporting materials
 

Change 6: Flexible working patterns

Seven-day working, weekend working and extended hours for services across health and social care can deliver improved flow of people through the system. Prioritise the services that will have the biggest impact in improving flow and outcomes.;
 

Making it Real’- I/We statement
I can choose who supports me, and how, when and where my care and support is provided.
We make sure that people can rely on and build relationships with the people who work with them and get consistent support at times that make sense for them."

Tips for success

  • Consider your system’s demand, capacity and bottlenecks (see change 2) and identify where extended hours or weekend working could have the biggest impact. Local systems tell us that seven-day working does not need to be in place across the whole system for benefits to be seen. Be prepared to start somewhere even if corresponding services are not in place.
  • To carry out the activity above, it is helpful to understand the current profile of discharges through the week so there can the appropriate planning and adjustment.
  • Take a pragmatic approach to responding to your system’s need: this does not need to be 24/7 working across all services; instead it is about placing staff well to ensure consistent flow throughout the week. This should include understanding the need of pharmacy, transport and availability of social care. 
  • Think broadly about your whole system: identify where seven-day working could be helpful across health and social care, including pharmacy, transport and housing services. Talk to all partners, including care providers and work out cost implications. 
  • Developing trusted assessment (change 6) can help to enable individuals to be assessed throughout the week or at the weekend in the community setting.
  • Engage with practitioners to understand how increased seven-day working would affect them personally and what you can do to help. Don’t assume staff won’t work weekends – talk to them about how it could work. Ensure new staff are recruited on seven-day contracts where affordable, and ensuring rotas allow for sufficient cover to facilitate all necessary weekend discharges.
  • Consider how criteria-led discharge can alleviate pressures and enable hospital discharges in days of the week with lower and more junior cover.
  • This change is undoubtedly challenging, so work gradually and draw on shared best practice and resources.
     

Examples of emerging and developing practice:
 

Maturity levels

High Impact Change Model - Change 6 maturity levels

Supporting materials
 

Change 7: Trusted assessments

Using trusted assessment to carry out a holistic strengths-based assessment avoids duplication and speeds up response times so that people can be discharged in a safe and timely way.

‘Making it Real’- I/We statement
I am supported by people who listen carefully so they know what matters to me and how to support me to live the life I want, and I only need tell my story once.
We know how to have conversations with people that explore what matters most to them – how they can achieve their goals, where and how they live, how they can manage their health, keep safe and be part of the local community."
 

Remember a trusted assessment can be either: 

  • An assessment completed earlier in the persons’ pathway being used, with agreement, for a second purpose and thus avoiding a delay
  • An assessment carried out by a third party on behalf of another organisation, for example a health colleague carrying out an assessment for social care colleagues or community services or providers.
  • And they can be used in a variety of settings, such as:

    - to agree restarts and ensure the person gets home more quickly
    - to support hospital discharge to a residential or a community service, in place of the provider carrying out their own assessment
    - to move between services
    - to make a local authority eligibility determination.

 

Tips for success:
 

  • Think about using trusted assessment both wherever there is a delay caused by an assessor not being able to do their assessment when needed – including access to home care, and to avoid duplicating where not necessary both for the benefit of the individual and the system.
  • Consider how trusted assessment interlinks with home first and discharge to assess – think holistically about your approach to the changes.
  • To enable good quality interactions in assessments, ensure professionals collect relevant information from other sources in advance of a face-to-face conversation. System information and the current support plan will be effective way to gather information, and to avoid people feeling like they are ‘starting from the beginning’ or having to tell their story multiple times.
  • Without trust between partners, trusted assessment will not work. Think about how to achieve and build trust to avoid poor outcomes for people. It is helpful to establish a set of common/shared objectives for a trusted assessment service. Trusted assessments can only be used with the agreement of all parties, so a co-design approach is essential. This involves engagement with care providers too. The process should be streamlined and simple.
  • The experience of patients should also contribute to the design process. As the process is implemented, feedback should be regularly collected to review and improve the process and patient experience.
  • People should be informed that it is not best practice to make decisions about a permanent move when they are in hospital.
  • When a local authority is governing the delegation of assessments, refer to the checklist found in the ‘Proportional assessment approaches: a guide from the Chief Social Worker for Adults and principal social workers’ guidance.
  • There are many methods of assessment, and it is important to decide the right method of assessment at the right time. Factors to consider are:
     
    • what is right for the person, considering levels of autonomy and control, communication needs and ability to use technology
       
    • whether the person has an appropriate person to represent or support them who can remain suitably independent
       
    • the complexity, concern or urgency of the situation and the local authority intervention required
       
    • the level of engagement with the local authority by the person and/or their family or friend carers

In addition to the checklist, it is important for any agreement for trusted assessments to include:

  • process to be followed when services and providers are concerned about not being able to meet a person’s needs after discharge
  • how providers and services can raise concerns about agreements and processes
  • how providers and services can withdraw from agreements in which they have lost confidence 
  • remember that the delegation of assessments does not absolve the local authority from ultimate responsibility for ensuring the function is carried out in accordance with all relevant statutory obligations. One way to enable this is to ensure that trusted assessors have access to supervision and support from regulated professionals who can ensure assessments are of good quality and comply with the Care Act.

Examples of emerging and developing practice:
 

Maturity levels
 

High Impact Change Model - Change 7 maturity levels 

Supporting materials
 

Change 8: Engagement and choice


Early engagement with people, their families and carers is vital so they are empowered to make informed decisions about their future care. A robust choice protocol, underpinned by a fair and transparent escalation process, is essential so that when people have capacity they can understand and consider their options.
 

‘Making it Real’- I/We statement
I can get information and advice that helps me think about and plan my life.
We provide information to make sure people know how to navigate the local health, care and housing system, including how to get more information or advice if needed."
 

Tips for success
 

  • Ask from the point of admission who they wish to have involved or informed in discussion and decisions about their discharge.
  • Where appropriate people are entitled to an independent advocate to support with their discharge decisions - ensure that people are aware of this option and know how to access it. Where there is a legal duty to provide an Independent Mental Capacity Advocate (IMCA) ensure that this is done as early as possible.
  • Talk to people (including family and friends) on or, where possible, before admission about their likely discharge route (see change 1).
  • Provide information in community settings and on wards about discharge routes.
  • Be creative to deliver the message in the best way for people e.g. use videos in waiting rooms, or leaflets in mailings. Take a co-design approach and involve patient groups and other organisations in developing the message.
  • Get the whole team involved, it’s everyone’s business.
  • Don’t be afraid to be clear – waiting in hospital is not an option, but people must know what their available options are.
  • Utilise key messages and communications support issued as part of initiatives to reduce length of stay in hospital – these should focus on information around harm and deconditioning as the key drivers to people and their families and carers to seek earlier discharge.
  • Work with colleagues across the health and social care system to manage people’s expectations of the care they will require after discharge, and to avoid unrealistic claims about the support people will receive. Managing expectations requires giving people the right information and advice throughout so they are fully informed.
  • Remember long-term decisions should not be made in acute hospital. D2A and other intermediate care are not subject to a choice protocol but should be seen as the next stage in the treatment programme.
  • Remember the Care Act 2014 guidance on choice of accommodation is that while any choice should be real they should also be within the personal budget and practicable.
  • Do involve the voluntary sector to support discharge.
    People who fund their own support are often forgotten. It is important to engage with everyone to provide appropriate information and support so that everyone can make informed decisions. 
  • Do carry out a demand, capacity and quality audit of your independent care market, as a system.
  • Try to avoid the need for choice letters, but when necessary don’t be afraid to issue them, as they are in the person’s best interest.
  • Ensure the choice protocol is part of team induction training
  • It is important to support family and carers of people with dementia to understand how to best support and care for them.
  • Ensure that you are regularly capturing and reviewing feedback around people experience of the process.

Examples of emerging and developing practice:

Isle of Wight: Care navigators - the service was developed as a different way of working with and utilising the VCSE sectors, to build capacity in stretched services and support the island’s new model of care and system redesign.

Maturity levels

High Impact Change Model - Change 8 maturity levels 
 

Supporting materials
 

Change 9: Improved discharge to care homes

The NHS Enhanced Health in Care Homes framework supports ways to join up and coordinate health and care services to support care home residents. COVID has strengthened these healthcare links, ensuring safe transfer from hospital to home, and making greater use of solutions including digital technology.

 ‘Making it Real’- I/We statement
I have a place I can call home, not just a ‘bed’ or somewhere that provides me with care 
We have a ‘can do’ approach which focuses on what matters to people and we think and act creatively to make things happen for them."

Tips for success:

A person should not be making long-term decisions about their care from a hospital setting. See change 5, for further support and guidance on how people can be supported to move to a suitable environment from where they can make decisions. 

The below top tips are focusing on care home restarts or where there is an exceptional circumstance warranting discharge to a care home from hospital. Keep in mind that those discharged directly to care homes need the same access to rehabilitation, recovery and reablement where that is appropriate.

  • Join your local care forum to hear what providers find unhelpful about admission from hospital and to get their input in demand and capacity planning.
  • Refer to best practice in discharge planning as can be found in other high impact changes, particularly change 1 and the supporting material. Involve care homes in the discharge planning process, and provide them with the information they need in good time. Explore with care homes the possibility of seven-day working or running on adaptive basis to avoid delays in weekends and out of hours. Change 6 explores flexible working in more detail.
  • Find out the top reason causing care homes to delay or refuse to take a discharge and fix it such as ensuring all medication sent home with people comes with clear guidance.
  • Ensure each care home is linked to a consistent, named GP and wider primary care service.  
  • Provide access to out-of-hours/urgent care to prevent unnecessary hospital admissions and to support care home staff. Areas have taken an innovative approach to this – for instance Airedale’s telehealth hub connects local care homes directly with the MDT. 
  • Develop channels for sharing information with care homes – such as NHSmail accounts. 
  • Step-down facilities must be available for those unable to return to their care setting because of infection in the care home. Digital solutions are vital to maintain support.
    Involve your ambulance service in planning. It will have valuable information on care homes in need of support and can help develop solutions. Include care homes in system conversations.
  • Link work on Enhancing Health in Care Homes with other high impact changes.
  • Consider how your system can provide enhanced services to better support vulnerable people in community settings, such as through rapid response.
  • Build on the existing learning and training opportunities to ensure that staff who are employed by social care providers receive a wide range of training and development opportunities. 
  • See the NHS guidance on Enhanced Health in Care Homes for additional components of this work which can support your system. Evidence shows certain relatively small investments can yield significant results both for people and the system.


Examples of emerging and developing practice:
 

  • Wirral care home teletriage service - Care homes have been provided with HD iPads and secure nhs.net email addresses to access a triage service, and staff have been trained to take basic observations and equipped with blood pressure monitors, thermometers, urine dip sticks and pulse oximeters. 
  • East Surrey care home multi-disciplinary project - Aim of the project was to enhance the level of care to all residents of care homes by increasing GP time to support care homes; care coordinated approach; and improved medicine management support and training.
     

Maturity levels
 

High Impact Change Model - Change 9 maturity levels 

Supporting Materials