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 Five Year Forward View and 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.
The NICE Pathway on this topic has interactive flowcharts that show how the recommendations in the guideline fit together with our other products on transfer of care. The following video explains how to use NICE Pathways.
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.
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.
- 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.
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