Discharge to Assess

The process for discharging patients is changing from Assessment, Discharge and Withdrawal to Discharge to Assess. This guide looks at the differences in the models, what it means for Trusts and local authorities and how we’re supporting you. 

Last year, 20.8% of all transfer of care delays were due to patients waiting for a care package in their own home. Transfer of care delays frustrate patients who want to go home and places a burden on hospitals that need to manage their bed occupancy. The source of these delays is often due to inefficiencies when patient information is transferred between a hospital and the local authority. 

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In response to the Covid-19 Pandemic, care teams needed to find ways of reducing the number of people in hospital settings. This led to the government suspending the Care Act, meaning that social workers would no longer complete assessments within the hospital setting.  

According to NHS England, for older people in particular, we know that longer stays in hospital can lead to worse outcomes and can increase their long-term care needs. But with the onset of the Covid-19 pandemic in 2020, longer than necessary stays in hospital have increased risk for all patients. 

“Wherever possible, people should be supported to return to their home for assessment. Implementing a discharge to assess model where going home is the default pathway, with alternative pathways for people who cannot go straight home, is more than good practice, it is the right thing to do.” Source

From March 2020 there was urgent pressure to free up 15,000 NHS beds for the anticipated wave of COVID-19 admissions. Hospitals, in effect, closed to all but urgent and emergency care. The government guidance applicable at that time directed rapid discharge of everyone clinically ready. Transfer off wards should be within one hour of a discharge decision to a designated discharge area, and then discharge from hospital as soon as possible, normally within two hours. 

The government supported the Discharge to Assess model, which enables the assessment to take place in the community after the patient is discharged from hospital. It has now been confirmed that Discharge to Assess will be the ongoing standard for discharges from Acute Hospitals into Social Care. 

Servelec working with Nottinghamshire County Council to enable interoperability between the Council and local healthcare trusts

“Nottinghamshire County Council have been trailblazers in developing a solution that enables social care staff to view a person’s up to date health information which saves time and enables them to be discharged more quickly and safely from hospital. This has not only benefited our staff, but also has helped to free up hospital beds and ensure people are supported to return to independence in the right environment.”

Melanie Brooks, Corporate Director for Adult Social Care and Health at Nottinghamshire County Council

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Within Discharge to Assess, assessments take place in the community after patients have been discharged from hospital. Due to the change people’s length of stay in a hospital bed decreases due to longer-term assessments taking place, with evidence to suggest patients are now being discharged from hospital on average three days earlier than before. It’s also been reported that 13.5% of social workers time is saved by having up-to-date clinical data. 

Improving the patient experience

  • Referrals are sent right first time to the correct Local Authority ​ 
  • The referral is constantly updated with any changes to the patient's status, such as ward location, medically fit status and deaths​ 
  • Patients and carers will not need to provide information multiple times to the hospital ​ 
  • Information provided by the Care Data Service​ 
  • Patient’s average length of hospital stay is reduced by more than three days​ 
  • Patients are discharged from hospital quicker and can continue their recovery with the appropriate care package in place at home/community setting 

Helping social workers provide the right care 

  • Better manage their time as referrals arrive on time and are updated real time if anything changes​ 
  • Notifications of patient death means they offer appropriate support to a bereaved family​ 
  • Notification of changes to patient's location means they no longer waste time contacting the wrong ward​ 
  • Allows them to be more efficient and reduce the amount of time wasted putting care packages together as they are constantly updated about the patient's situation​
  • Able to arrange timely intervention with the right services​ 
  • Reduces manual work significantly 
  • Can view updates to the case at a glance using the Case Management Log in Mosaic 

Helping services use resources more effectively 

  • No delays and errors reduced​ 
  • Reduction of inefficiencies from the digitisation of the process​ 
  • More up to date information allows for better ability to plan workforce and provide better care​ 
  • Appropriate next steps for care can be arranged in a timely manner​ 
  • Improved service delivery​ 
  • All information received electronically, directly into the Mosaic record reducing manual work 

Discharge to Assess brings continuity of health and social care to Nottinghamshire

Learn how Nottinghamshire County Council and local healthcare trusts now get the same up-to-date view of patient progress and history, making referrals both quicker and safer.

Download full case study (163 KB)

Key features

Created in partnership with Nottinghamshire County Council and powered using our Conexes Interoperability Platform, Discharge to Assess is designed to digitise and streamline the process of supporting a patient's discharge from Health to Social Care. The Discharge to Assess package has been developed using a set of FHIR standards to allow for national interoperability in a project backed by NHS Digital Pathfinder funding, the integrations offer real-time, and secure access to important data across the care journey. 

New features have also been developed to improve the quality of information sharing between Health and Social Care, which has provided a significant enhancement from our previous ADW product which it will replace. 

If you’d like to find out more about the change to Discharge to Assess, please get in touch below. 

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