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Transfers of care: Guidance for providers
Moving between hospital and home or care home

Ewan King explores recent guidance to support people moving between hospital and home or care home.

Our Chair at the Social Care Institute for Excellence Paul Burstow, recently said that so much has been written about transfers of care that it is sometimes hard to see the wood for the trees. So, where do you start in addressing the issue?

One starting point is to realise that transfers of care are not just about transferring people from hospital. It’s vital that other moments on a person’s journey to and from hospital are dealt with properly and by a multi-disciplinary team.

All of this should be underpinned with a personalised approach to providing care and support; staff in care homes, hospitals and elsewhere must adopt a person-centred approach for everyone they offer care and support to. Does that sound daunting?
Well, you’ll be pleased to know that a big difference can be made by attention to the small details.

Quick guide to transfers of care

A new quick guide from ourselves and the National Institute for Health and Care Excellence (NICE) looks at both the small things that can help transfers of care and also the complex issues that lie behind transfers to and from hospital. The guide is based on the NICE guideline Transition between inpatient hospital settings and community or care home settings for adults with social care needs.

In the guide, we look at provision for people who are moving between hospital and home, including care homes. It’s only four pages long, but we feel it gives enough information in an accessible way, to really support managers in providing the best experiences for people moving between home and the community.


The guide starts by getting the care and support worker to ask where the person being transferred wants to be. This is because, when people with care and support needs transfer into and out of hospital, good communication and integrated services are essential.

Registered managers and their teams have an important role to play in this, as part of the community-based team supporting people who are transferring in and out of hospital. The community-based team have a role in: addressing unmet care and support needs, avoiding unnecessary hospital readmissions and admissions to care homes, and addressing delayed transfers of care.

As such, it’s important to ensure that the person, their carers and all health and social care practitioners involved in someone’s move between hospital and home are in regular contact with each other. This can include things like making sure that written material appears in Plain English. Good communication is important to ensure that any transition is well-coordinated and that all necessary arrangements are in place.

Beyond communication, there is also a number of things that can be done before admission, at the time of admission, and at discharge from hospital.

Before admission

It’s good to think about who might be at risk of hospital admission and to support them to make a care plan in case this happens. Even though it might not seem like the time to think about it, it’s a good idea to also make sure that you are familiar with the hospital’s discharge planning protocols and processes.

Before someone is admitted to hospital, health and social care practitioners and advocates should explain to the person, and their family, what type of care they might receive when they arrive in hospital.

What happens on admission?

When someone is admitted to hospital, the admitting team need to have all the information they require about the person who is arriving at hospital. This might include:

  • Care plans, including any preferred routines, and advance care plans.
  • Communication and accessibility needs.
  • Current medicines.
  • Triggers to behavioural issues.
  • Details of family, including carers and next of kin.
  • Housing issues.
  • Preferred places of care.

Even at this sometimes-early stage, all relevant practitioners should start assessing the person’s ongoing social care needs and start discharge planning, even if this seems counter-intuitive.

Added to this, to provide person-centred care, it’s best to encourage people to follow their usual daily routines as much as possible during their hospital stay.

During the hospital stay

As soon as the person is admitted to hospital, identify the staff who form the hospital based multidisciplinary team that will support them, such as doctor, dietician, social worker, housing specialist.

Registered managers can also keep in touch with the hospital team and share any information that might affect discharge planning.

In the hospital, work can be done with the discharge co-ordinator to help develop the discharge plan. It’s never too early to start this process. For instance, at each shift handover and ward round, members of the hospital based multidisciplinary team should review and update the person’s progress towards hospital discharge.

When discharged

NICE guidelines on discharge are clear: make a single health or social care practitioner responsible for co-ordinating the person’s discharge from hospital. This co-ordinator can keep in touch with people who are supported at home and must make sure that the individual knows how to contact your service if they need to.

What you can expect from the hospital team

In the quick guide, NICE and SCIE talk about ‘discharge planning principles’. These are:

  • Ensure people experience continuity of care.
  • Decisions about long-term care should only be made after a crisis has been resolved.
  • Discharges need to be planned and co-ordinated, despite any pressure on freeing up hospital beds.

As we say above, it’s important to start discharge as soon as possible after arrival. This includes having contact with a named discharge co-ordinator, who should do things like arrange follow-up care, including any specialist equipment and support.

Crucially, a copy of the discharge plan, including things like medicines being taken, contact information for after discharge and details of useful services, should also be made available to people who are offering ongoing care and support in the community.

Quick guides from NICE and SCIE

Moving between hospital and home, including care homes is one of a series of quick guides that have been developed to meet the needs of busy frontline health and social care professionals. The others are on planning for children and young people transitioning to adult services and recognising and preventing delirium.

Hospital transfers aren’t solely about avoiding unnecessary admissions. That’s one part of it undoubtedly, but it’s also important to remember the whole journey someone may experience from a community setting, to hospital and back again.

Registered managers and their teams have an important role to play as part of the community-based team, supporting people transferring in and out of hospital. Thinking beyond the obvious, for instance by planning discharge when someone actually arrives at hospital, is a good way to make sure that someone’s journey to and from hospital is as good an experience and as person-centred as possible.

Red bag scheme: simple but effective help on admission to hospital

Sutton Homes of Care has launched a simple idea to help care home residents to receive quick and effective treatment should they need to go into hospital in an emergency. The red bag keeps important information about a care home resident’s health in one place, easily accessible to ambulance and hospital staff.

It also has room for personal belongings (such as clothes for day of discharge, glasses, hearing aid, dentures etc) and it stays with the patient whilst they are in hospital. When patients are ready to go home, a copy of their discharge summary (which details every aspect of the care they received in hospital) will be placed in the red bag so that care home staff have access to this important information when their residents arrive back home.

The red bag also clearly identifies a patient as being a care home resident and this means that it might be possible for the patient to be discharged sooner. This is because the care home has been involved in discussions with the hospital and has an understanding of the resident’s care needs, so they are able to support the resident when they are discharged. Communication between care home staff and trust staff has improved greatly because of the red bag and staff say they now have a better understanding of each other’s roles.

The red bag scheme has been developed in partnership with Epsom and St Helier Hospital Trust, Sutton and Merton Community Services, London Ambulance Service and staff from Sutton care homes. It has been rolled out in other areas of the country.

Ewan King is Director of Business Development and Delivery at the Social Care Institute for Excellence (SCIE). Email: Twitter: @EwanDKing

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