Discharge Planning
Effective discharge planning is a structured process beginning at admission to ensure safe, timely transition from hospital to home or appropriate care setting, reducing readmissions and improving patient outcomes.
Key Facts
Discharge planning should begin at admission — not as an afterthought when the patient is medically fit Estimated Date of Discharge (EDD) should be set within 24 hours of admission and communicated to patient/family Discharge to Assess (D2A): model where patients are discharged when safe (not necessarily fully recovered) and assessed for ongoing needs in their usual environment 4 D2A pathways: 0 (simple discharge), 1 (home with support), 2 (rehabilitation/reablement facility), 3 (complex assessment for long-term care) Delayed discharges cost the NHS approximately £300 million/year and harm patients through deconditioning and hospital-acquired complications Medication reconciliation: essential at discharge; ensure accurate medication list, patient/GP letter, compliance aids if needed Communication: discharge summary to GP within 24 hours; must include diagnosis, investigations, medication changes, follow-up plan Red flags for unsafe discharge: unstable medical condition, unresolved safeguarding concerns, no safe living environment, unassessed capacity for discharge decision
Overview
Key Facts
Good discharge planning reduces length of stay, readmissions, and patient harm. It requires a multidisciplinary approach and close coordination with community services.
Epidemiology
- ~10-15% of hospital beds in England occupied by patients who are medically fit for discharge ("delayed transfers of care")
- 20-25% of older adults are readmitted within 30 days of discharge
- Average excess LOS for delayed discharge: 7 days
- Delayed discharge associated with increased mortality, functional decline, and hospital-acquired infection
Aetiology
Common reasons for delayed discharge:
- Awaiting social care assessment/package
- Awaiting care home placement
- Awaiting community equipment/adaptations
- Family/patient choice
- Awaiting further NHS care (rehabilitation)
- Safeguarding concerns
Pathophysiology
- Prolonged hospital stay → deconditioning, nosocomial infection, delirium, falls, pressure ulcers, loss of independence
- Hospital environment is disorienting for older adults (unfamiliar, noisy, disrupted sleep-wake cycle)
- Each day of unnecessary hospital stay increases mortality risk and reduces functional recovery
Clinical Presentation
Discharge Planning Process
- Admission: identify likely discharge needs; set EDD
- During stay: daily MDT review; progress against goals; update EDD
- Pre-discharge: medication reconciliation; discharge summary; patient/family education; arrange follow-up; community referrals
- Discharge day: ensure transport, medications, equipment, care package in place
- Post-discharge: follow-up (GP, community teams, outpatient)
Assessment for Discharge
- Medical stability (not necessarily full recovery)
- Functional ability (can manage at home with support?)
- Cognitive assessment (safe to return home?)
- Medication understanding and supply
- Social support (carers, package of care)
- Home environment (safe, appropriate equipment)
- Follow-up arrangements
Red Flags for Unsafe Discharge
- Medically unstable
- Unresolved safeguarding concerns
- Inadequate social support with high care needs
- Patient unable to manage medications safely without planned support
- No safe living environment
- Unassessed capacity for high-risk discharge decisions
Differential Diagnosis
| Discharge Pathway (D2A) | Description | Proportion |
|---|---|---|
| Pathway 0 | Simple discharge; no additional support | ~50% |
| Pathway 1 | Home with new/enhanced support | ~30% |
| Pathway 2 | Short-term bed-based rehabilitation | ~15% |
| Pathway 3 | Complex assessment (care home likely) | ~5% |
Diagnosis / Investigation
Bedside
- Functional assessment (Barthel, mobility, ADLs)
- Cognitive screen (4AT, AMT — can patient manage at home?)
- Medication review and reconciliation
- Home environment review (OT home visit or telephone assessment)
- Carer assessment
Bloods
- Ensure stable results before discharge (U&Es, INR, glucose)
- Arrange follow-up bloods with GP if needed
Imaging
- Not specific to discharge; ensure pending results are followed up
Special Tests
- Capacity assessment if patient refuses care or makes high-risk decisions about discharge
- Falls risk assessment before discharge
- Nutritional assessment (MUST)
Management
Non-pharmacological
- Set EDD within 24 hours: communicate to patient, family, and MDT
- Board/huddle rounds: daily MDT review of discharge plan
- Criteria-led discharge: empower nursing and therapy staff to discharge when criteria met
- Home assessment: OT virtual or in-person home visit if needed
- Equipment provision: community equipment service (grab rails, commode, raised toilet seat, hospital bed)
- Care package: arrange domiciliary care (personal care, medication prompts, meals)
- Intermediate care/reablement: time-limited support to restore independence
- Patient and family education: diagnosis, medications, when to seek help, follow-up plan
- Discharge summary: to GP within 24 hours; clear, accurate, complete
Pharmacological
- Medication reconciliation: review all medications; stop unnecessary drugs; document changes and reasons
- Discharge prescription: ensure sufficient supply (minimum 14 days); compliance aids (dosette box) if needed
- Anticoagulation: ensure INR monitoring arranged; DOAC monitoring if applicable
- Controlled drugs: appropriate supply and documentation
Surgical/Interventional
- Not specifically applicable
Referral Criteria
- Complex discharge: MDT planning meeting
- New care needs: social services referral
- Rehabilitation needs: community rehabilitation/intermediate care
- Palliative care: community palliative care team
- Safeguarding: local authority
- GP follow-up: ensure continuity of care
Prognosis
- Effective discharge planning reduces readmission by 20-25%
- D2A model reduces LOS and improves patient satisfaction
- Failed discharge (return to hospital within 48 hours): approximately 5-10%; often related to inadequate planning
- 30-day readmission rate: approximately 20% for older adults (higher in heart failure, COPD, pneumonia)
- Patients who experience delayed discharge have 10% higher mortality at 6 months
- Good communication between hospital and primary care reduces readmission risk
Other Relevant Information
Discharge to Assess (D2A) Pathways
| Pathway | Description | Assessment Location | Services |
|---|---|---|---|
| 0 | Simple discharge | N/A | No new support needed |
| 1 | Home with support | At home | Domiciliary care, community therapy |
| 2 | Rehabilitation | Bed-based unit | Short-term rehabilitation/reablement |
| 3 | Complex assessment | Bed-based | Continuing healthcare assessment |
Discharge Summary Requirements
| Component |
|---|
| Diagnosis and problems managed |
| Procedures and investigations (with pending results flagged) |
| Medication changes (and reasons) |
| Discharge medications (with duration) |
| Allergies |
| Follow-up plan |
| Outstanding actions for GP |
| Patient's functional status at discharge |