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If there is a change, notify/liaise with multidisciplinary team and community services.

(c) If NO change within 24 hours of discharge, confirm that: Patient is medically fit for discharge

All community services are in place as agreed

Patient has drugs to take out (TTO) and next appointment

Ensure patient has drugs TTO with written and verbal instructions.

Next in/outpatient appointment as required.

Access to home, heating and food are checked.

Check arrangements for patient to get into home (front door key), heating, food and someone there to welcome them home, as appropriate.

5 Hospital equipment: for example syringe drivers: ensure clearly marked and arrangements made for return

6 After discharge, follow-up phone call to patient by ward nurse/complex discharge co-ordinator as agreed to ensure all is well

Discharge at end of life

The End of Life Care Strategy (DH 2008) requires that assessment is made of the patient’s preferred place of care and where they wish to be cared for at the end of life. There may be occasions when a patient is reaching the end of life and the decision is made that their preferred place of care/death is home. Then every effort must be made to ensure that all practicable steps are taken to allow that to happen (Vaartio et al. 2006). It is important to contact the District Nurses, the community palliative care team and (where available) the community matron at the earliest opportunity. A fast-track NHS Continuing Care Funding application may need to be submitted to access funding for the care provision. The patient may also require essential equipment to enable them to return home, such as bed, commode or hoist; again, these should be ordered at the first opportunity. Once care and equipment are in place and discharge is proceeding, ensure that a medical review takes place and that the GP, District Nurses and community palliative care team are provided with a copy of the discharge summary. Telephone contact with the GP prior to discharge is essential to ensure they visit the patient at home.

Anticipated patient outcomes

To ensure patients have a safe and timely discharge from hospital to the community.

To ensure patients and carers are involved throughout the discharge planning process.

To provide patients and carers with written and verbal information to meet their needs on discharge.

To provide continuity of care between the hospital and the agreed environment by facilitating effective communication.

(Adapted from DH 2004a)

Preprocedural considerations

It is essential that nurses are aware of their trust’s discharge procedures and protocols.

Single assessment process

Referred to in The NHS Plan (DH 2000a) and reinforced in The National Service Framework for Older People (DH 2001a), the Single Assessment Process is designed to replace fragmented assessments carried out by different agencies with one seamless procedure (Hunter 2001). The aim is to produce a single, centrally held, electronic summary/tool containing all the information needed to assess and provide for an older person’s health and social care needs. The end result will be a comprehensive ‘individual care plan’ that will lay out their full needs and entitlements (Hunter 2001). Although there has been a high level of commitment to the Single Assessment Process from both health and social care professionals, implementation has occurred at different rates. It appears that more progress has been made in the community rather than hospitals and general practitioner practices (NHS Connecting for Health 2005). Work continues on the development of a data-sharing system that will allow previous assessments, carried out before a hospital admission, to be shared across the NHS, preventing the need for patients to go through the assessment process more than once.

Intermediate care

The National Bed Enquiry (DH 2000b), The NHS Plan (DH 2000a) and The National Service Framework for Older People (DH 2001a) signalled the development of intermediate care as one of the major