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initiatives for services in the future. It is recognized that older people are best cared for at home if at all possible. To aid the transition period from hospital to home, intermediate care teams may provide a period of intensive care/rehabilitation following a hospital stay, which may take place in a care home or in the individual’s own home. It is likely to be limited to a maximum of 6 weeks but there are local variations in practice. Intermediate care needs to have a person-centred approach involving patients and carers in all aspects of assessment, goal setting and discharge planning. Its success depends on local knowledge of the service and interagency collaboration (Hancock 2003). There is growing evidence suggesting that intermediate care initiatives reduce admissions to acute hospitals and residential/nursing home placements (DH 2002).

Discharge to a care home

Discharge to a care home (whether a residential or nursing home) requires careful thought as giving up their own home is one of the most traumatic events that a person has to consider. A thorough multidisciplinary assessment is essential, taking into account the individual needs of the patient and carer and exploring all the options before agreeing on a care home. Placements can be delayed while waiting for a vacancy and it may be necessary to consider an interim placement (DH 2003a).

In 2001 there were important changes in the funding arrangements for adults requiring registered nursing care in nursing homes in England (DH 2001b). All adults needing the skills and knowledge of a Registered Nurse to meet all or certain elements of their care needs have that care paid for by the NHS. The amount of funding, paid directly to the nursing home, is dependent on a comprehensive assessment of the patient’s care needs by a Registered Nurse, who will usually be employed by the local primary care trust. NHS-funded nursing care was originally provided via payment ‘bands’, which relate to the level of nursing care required. However, the National Framework (DH 2006b), which came into effect in October 2007, replaced the banding system with a weekly rate for NHS-funded nursing care.

NHS Continuing Healthcare

NHS Continuing Healthcare is a general term that describes the care that people need over an extended period of time as the result of disability, accident or illness, to address both physical and mental health needs. It may require services from the NHS and/or social care. It can be provided in a range of settings, for example, from a care home to care in people’s own homes. NHS Continuing Healthcare is a package of care arranged and funded solely by the NHS. It should be awarded when it is established (through multidisciplinary comprehensive assessment) that an individual’s primary care need is a health need. There has been inconsistency in applying the criteria nationally (House of Commons Health Committee 2005), resulting in the Department of Health producing a National Framework for NHS Continuing Healthcare (DH 2006b).

In October 2009 the new national tools for NHS Continuing Care were launched. These replace any previous tools, including the fast-track assessment for those patients who have a rapidly deteriorating condition. There is a legal obligation to inform patients of their right to be assessed for NHS Continuing Care funding. There is a booklet informing patients of their rights and outlining the process (DH 2007). Patients who may be entitled to funding through this process could be paying unnecessarily for their care through Social Services as they will have been financially assessed.

Procedure guideline 2.1 Discharge planning

Preprocedure

Action Rationale

This is the initial assessment (at the preadmission clinic or within the first 24–48 hours of admission).

1 The admitting nurse is responsible for ensuring that an initial assessment is completed when the patient is admitted and is documented in the patient’s care plan. Assessment should be ongoing and regularly reviewed with the multidisciplinary team. To enable the physical, psychological