Business Clinic
Discharge home to assess – Benefits of this new model of care

Agincare, Portsmouth City Council and Queen Alexandra Hospital have successfully proven the benefit of Discharge to Assess (D2A) using live-in care. Is it a solution for sector pressures?

Pressure on the NHS from delayed transfers of care, coupled with pressure on local authorities to deliver timely assessments of people ready for discharge, is creating a bottleneck in the system. Latest figures on delayed transfers of care from NHS Digital indicate that there were 177,100 total delayed days in April 2017, of which 115,600 were in acute care. 55% of all delays were attributable to the NHS, 37.9% to social care and the remaining 7.1% to both NHS and social care.

There’s clearly a need to address this and find solutions to the issues which, in general, aren’t easing.

Discharge to Assess

As new models of care are developing across the sector, and Better Care Funding is being used to help drive integration and new ways of working, one model has emerged as a potential solution to help delayed transfers of care.

D2A has been set up as a way to ease the pressures and help people back into the community for assessment.

NHS England’s Quick Guide: Discharge to Assess defines it as, ‘Where people who are clinically optimised [medically-fit to leave hospital] and do not require an acute hospital bed, but may still require care services, are provided with short-term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person.’

However, it requires the NHS, local authorities and care providers to work together to create a suitable pathway, to support people out of acute settings. Beyond that, it requires partnership, conversations between all stakeholders and the right attitude to find solutions that make a difference to people’s lives in a time of immense pressure.

Pilots are popping up across England to develop D2A pathways and evaluate their effectiveness for patients, the NHS and local authorities. As with any new initiative, different areas are taking different approaches.

In Portsmouth, Agincare, in partnership with Portsmouth City Council and Queen Alexandra Hospital, has developed its model around the flexibility of its live-in care workforce.

Portsmouth pilot

The Portsmouth D2A pilot set out to offer clients and patients real choice to return or remain at home safely with the right support. Set up in May 2016 to run for 18 months, its aim was to reduce the number of people permanently admitted to long-term care, reduce length of hospital stays and excess bed days, reduce delayed transfers of care, increase the number of people transferred home from hospitals and reduce the number of people admitted to hospital. It was originally conceived as a reablement pathway, but now also provides discharge pathways for end of life care, patients with dementia and community-based hospital admission prevention.

Its underlying principle is to offer patients greater reassurance, supporting the transition from an acute setting to home with anything up to round-the-clock support of a live-in care companion.

The 18-month block contract guaranteed rolling discharge capacity of five live-in care workers per week, providing a maximum two-week intervention for each potential discharge patient. During the contract, this increased to eight workers with additional spot purchasing available. The live-in care workers trained alongside the NHS and adult social care, and a frontline manager supported the collaboration.

The live-in care workers offer practical support, enabling assessment at home within 48 hours, and offering anything up to 24-hour support and continued assessment for a short period as determined by the commissioner. The scheme is also able to respond to emergencies to prevent admission and support people prior to admission.

Over the period of the contract, the pilot evolved, with referrals doubling after six months and expanding to meet changing priorities and demand.


The pilot achieved evidence and outcome-based commissioning that flexes with demand. The service helps to fill gaps in capacity and deliver a more comprehensive service for a limited time. Health and social care teams adapted their commissioning to include the service as part of a range of solutions to enable hospital discharge and prevent readmission.
Over 12 months, adult social care saved £52,000 p/a by reducing avoidable residential placements.

For the NHS, savings totalled £378,000 by reducing delayed transfers of care by an average of 18 days in hospital. Also, only 6.5% of patients involved in the pilot were readmitted to hospital, against a national average of 12.2%, as calculated by the Nuffield Trust.

Tracking patients after 12 months of delivery, 69% receive domiciliary care or no care at all.
Beyond this, the pilot increased trust and understanding between systems, helping to remove some of the pressure and enabling them to function outside of crisis mode. It also enabled Portsmouth City Council to adapt and evolve its ideas and pathways with a trusted provider partner without the risk of compromise from a lack of capacity, continuity or quality.


The scheme has been extended to two years, with Portsmouth City Council announcing its intention to re-commission the service for a further three years. Agincare and Portsmouth City Council have been nominated for a national award for the model. Agincare is rolling it out to new local authorities and NHS partners to meet local demands, strategic plans or sustainability and transformation partnerships.

The model has the potential to deliver single or multiple pathways for long-term service development, or to ease shorter-term winter pressures. It creates a single point of contact for reablement and rehabilitation teams. Plus, the live-in care workforce is able to work nationally and can be permanently based in any location.

Over to the experts…

What are your thoughts on this pilot and its outcomes? Does D2A have the scope to ease winter pressures, reduce delayed transfers of care and help with wider service transformation and integration across England and Wales? Would it work well in a suite of different models and pathways?

Innovation between commissioners and providers

Delayed transfers of care are a big headache, and doing more of the same is not an effective strategy. It’s therefore good to see innovation being fostered between commissioners and providers.

D2A pilots fit well with other approaches, such as Trusted Assessment, also being developed. Getting people back home safely, with short-term support where needed, is not only good for hospitals, but is the overwhelming preference for people. To be successful, care workers need to be able to support a reabling approach to help people maximise their independence. It’s therefore encouraging to see care workers training with NHS colleagues.

Live-in homecare is a service which councils and the NHS have historically been slow to adopt, but this pilot shows how it can be used creatively. Live-in care workers are generally engaged on an ‘unmeasured work’ basis, meaning that there is flexibility throughout the day to provide the necessary support, while ensuring that care workers receive a predictable wage each week. This contract has been procured on a ‘block contract’ basis, which provides certainty for a provider to recruit, train and develop workers. This is important for live-in care workers, who usually want the reassurance that they will have regular accommodation as part of their engagement.

Where D2A schemes can be let down is where there is an inability to source a care package to meet any ongoing support needs, and this needs to be considered when developing these services. As live-in care workers are generally willing to work in different areas, this model has the potential for providers developing it to offer services to other hospital trusts.

Colin Angel Policy and Campaigns Director, UKHCA 

With the right behaviours, it can be done

‘We usually have to fight to get support, but this was so easy.’ This quote, from a member of a family involved with the Discharge to Assess pilot, is what stood out for me and marked the scheme as a potential game-changer.

We know how difficult it is for people to navigate the health and care system; The Barker Review in 2014 described the lack of alignment and how harrowing some of the consequences could be. One description from a family member stands for many, ‘I know how the health and social care system is supposed to work, but I was powerless to influence…nothing was joined up, with each part of the system only interested in their part of the problem.’

The Portsmouth Council/Agincare initiative shows how good the outcomes can be when the system does join up, with the person at the centre. Fundamentally, it has significantly reduced length of stay in hospital, crucially important in preventing deconditioning in older people, quite aside from any financial savings that accrue to the NHS and the local authority. The flexibility of the service has meant that it could be deployed in a timely manner, which again lowered the risk of admission to hospital. And it was easy to access and obtain.

It has the potential to be revolutionary. But getting there didn’t require upheaval or re-structuring. It was about systems behaviours, a shared purpose, willingness to work together and people recognising the part others played.

If you’re tempted to walk away from integration, turn around and talk to Portsmouth and Agincare again. They’re proof that with the right behaviours, it can be done.

Debbie Sorkin National Director of Systems Leadership, The Leadership Centre 

All patients should have access to D2A

Imagine how you would feel if I told you today that you will never see your home again, that you will never be able to sit in your favourite chair and feel that sense of safety that being surrounded by your own environment brings.

As we all know, this is what currently happens every day to many of our older patients who move from hospital to longer-term nursing and residential homes.

It is for this reason that I am drawn towards the Discharge to Assess models of care, not only as a way of relieving pressure on services, but also of delivering services which are in the best interests of the patient.

The paper sets out clearly the benefits for systems. We must also consider the benefits for our patients and families. Too often, assessments take place in the acute setting after patients are medically stable and do not give a true reflection of patient’s abilities.

Discharge to Assess allows assessments to take place in the most appropriate environment once optimum reablement has been achieved. It can be used to support more patients returning home where this is their preferred outcome.

The Discharge to Assess model allows improvements in the quality of life for patients as well as more accurately assessing their abilities to cope in the normal settings.

The key point is that Discharge to Assess is able to deliver benefits to services and patients. I feel that all patients should have access to the Discharge to Assess model to provide them with the greatest possible choice about their future.

Kate Pound BSc MSc MPhil RGN Collaborative Manager, CHC Strategic Improvement Programme Horizons Team, NHS England 

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