NICE guideline on transition between hospital and community or care home

NICE – the National Institute for Health & Care Excellence - issued new guidance on hospital discharge for older people and people with a disability.

This guideline is for both commissioners and providers of services and emphasises the need for people to be placed at the centre of the services they need and use. This is the direction set by the Care Act last year; giving people choice and control even in hospital.

The new guidance sets out that a range of relevant information, including housing status, should be recorded by admitting teams early on (1.3.3) and that the admitting team has responsibility to discuss the possible options for getting home on discharge from hospital (1.3.5).

The key principles underpinning the transition from hospital back into the community should be that practitioners at all levels ensure people do not have to make decisions about long-term residential or nursing care while they are in crisis (1.5.11) or let pressure on beds result in unplanned or uncoordinated discharge. 

NICE suggests making a single health or social care practitioner responsible for coordinating a person’s discharge from hospital (1.5.1).  This discharge coordinator should be supported by discharge plans and protocols that take account of a person’s social and emotional wellbeing as well as ‘the practicalities of daily living’ (1.5.15). Crucially for HIA services, NICE recommends that the discharge coordinator discuss the need for specialist equipment(including housing adaptations (1.5.18))and support with primary health, community health, social careand housing practitionersas soon as discharge planning starts. This should ensure that essential equipment and support are in place at the point of discharge.

The guidance also encourages commissioners to ensure that a range of local health, social care and voluntary services are available to support people after they have been discharged (1.6.1). 

Input from Foundations and Care and Repair England during the consultation phase of the guidance has meant that NICE emphasise the important role of housing at key points in the document and give much greater prominence to housing needs and housing practitioners in key recommendations such as their presence in multi-disciplinary teams. 

Providers of HIA services should ensure that they are able to deliver services to the standards suggested in the guideline.  These are still evolving and will be subject to further consultation later in the year but expectations around the accessibility of information and collaboration are already part of the guidance. Of course, with the issue of NICE guidance there is also an opportunity to ensure that commissioning managers in CCG and Social Care structures are aware of the role that HIAs can and should play in the safe transition of people from hospital to home

Download the guidance