Improving transfer of care
How NICE resources can support local priorities
Making the case for improving transfer of care
Improving transfer of care is a priority for the health and care systems and a commitment of the NHS Long Term Plan. People may spend longer in hospital than they need to, or not receive the support they need after discharge. The ambitions of the Quality Matters include:
- Improving how hospitals work in partnership with social care services so that people don't get stuck, as part of urgent and emergency care transformation.
- Implementing elements of the Local Government Association’s high impact change model for reducing delayed transfer of care.
- Integrated working across health and social care to reduce delayed transfers of care.
Our guidance and quality standards can help you to deliver these ambitions in your local partnerships.
Finding the right information
Our guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs covers the principles of person-centred care for people before and during a hospital stay and at discharge.
Good communication is key to good transfers of care. The guideline includes recommendations on communication and information sharing between health and social care practitioners at every stage from admission to discharge.
A single health or social care practitioner should be responsible for coordinating the person's discharge from hospital. Planning needs to involve the person’s family or carers. It should also consider all aspects of the person’s life, and follow our recommendations on the importance of having a warm home. Follow up from community-based health and social care practitioners should be arranged when the person leaves hospital.
Our guideline and NICE Pathway on intermediate care (including reablement) cover assessment, person-centred planning and goal setting, and the importance of having a flexible, outcomes-focused approach. They also have recommendations on what people need to know before intermediate care finishes.
We also have a guideline and NICE Pathway on transition between inpatient mental health settings and community or care home settings.
Our quality standards help with identifying areas where you can make an impact by improving quality of care. Examples include:
- transition between inpatient hospital settings and community or care home settings for adults with social care needs – particularly the quality statements on information sharing on admission (statement 1), comprehensive geriatric assessment (statement 2), co-ordinated discharge (statement 3) and discharge plans (statement 4)
- medicines management in care homes, particularly the quality statement on sharing information (statement 2).
Putting guidance into practice
The guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs identifies 3 challenges for people putting the recommendations into practice:
- Improving understanding of person centred care.
- Ensuring health and social care practitioners communicate effectively.
- Changing how community and hospital based staff work together to ensure coordinated, person-centred support.
The guideline offers practical advice on how to meet these challenges. You can also find a range of tools and resources to help with putting this guidance into practice, including:
- information on the resource impact of implementing the guidance
- baseline assessment tools to check how well services are doing against the guidance
- an electronic discharge summary document produced by The Professional Record Standards Body.
Shared learning case studies
Reducing bed blocking and improving the transition from hospital to home
Thousands of beds in Kings Mill Hospital, Mansfield are being freed up thanks to the ASSIST hospital discharge scheme. In 9 months, more than 1,000 patients were transferred, saving the NHS £1.4 million.
Clinicians, social workers and housing staff work together as an integrated team. At the point of hospital admission, they identify and help vulnerable people who are in need of social and welfare support rather than emergency treatment.
They also identify and work with inpatients who are fit to go home but may need help, such as alterations to their home or temporary accommodation in a dedicated respite unit for people who may otherwise become homeless.
Intensive reablement at nursing home improves people's health and frees up hospital beds
Most (98%) patients at Yeovil District Hospital who agree to 10 days of intensive reablement at a nursing home are well enough to go home afterwards, and 42% don’t need as much home support as originally predicted. This has led to estimated savings of £1.6 million in care costs for the local authority and income protection estimated at £1.9 million for the NHS for 2017/18.
By October 2017, nearly 600 people had transferred to Somerset Care’s Yeovil nursing home. Members of the hospital rehabilitation team work with Somerset Care nurses to provide daily support from 8am to 8pm, based on a plan for independence drawn up with each patient.
Supporting best patient outcomes through a joint Discharge to Assess, Home First service
Bristol City Council, Bristol, North Somerset, South Gloucester CCG and Bristol Community Health worked together to redesign and deliver the Home First service that aimed to reduce delayed transfers of care and avoid placing too many patients directly into long term care before providing a period of intermediate care and assessment in their own home.
The Home First service brings secondary care, intermediate care, ongoing community support and the voluntary sector together to deliver a consistent approach to supported discharge, that will improve outcomes for patients and make best use of system resources by delivering the following:
• Patients discharged through their preferred route
• Discharge within 48 hours where medically fit
• Patients get a first visit from a clinician and receive proper goal setting in their home environment
• Exit plan is in place within 72 hours of people being discharged into the service.
Early data showed:
• 90% of Service Users finishing in Home First pilot remained at home
• 61% required no further support.
• 17% received further intermediate care
• Only 2% required a long term package of care straight from Home First.
Using quality standards to make an impact
Quality standards help you improve the quality of care you provide or commission. They contain quality statements describing priority areas for quality improvement.
They also include metrics that can be a useful source of:
- key performance indicators
- performance metrics for system-wide performance dashboards.
Our guide to using quality standards contains more details about how best to use them.
We've mapped our quality statements against the system changes identified by the Local Government Association’s high impact change model for reducing delayed transfer of care. The changes in this model cover every stage from early discharge planning to enhancing care in care homes.
As well as general aspects of improving transfer of care, our quality statements also cover points relevant for people with specific conditions. We've statements covering areas that have a direct impact on transfer of care, and on reducing length of stay.
Reducing delayed transfers of care
Reducing length of stay
Length of stay can be considered at the same time as transfer of care.
Other statements related to reducing length of stay
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