Hospital Discharge and Transitions of Care: A Guide for Care Homes

A hospital discharge is one of the highest-risk moments in a resident's care journey. Get it right and a person moves smoothly from ward to care home with the right equipment, medication and information in place. Get it wrong, and a care home can find itself receiving a resident with no discharge summary, no medication chart and no warning that a pressure sore has developed since admission. Understanding how the discharge process is supposed to work — and where care homes fit into it — is essential for any care setting that accepts hospital admissions.

The Discharge to Assess Model

Most parts of the NHS now use a "Discharge to Assess" (D2A) approach, built around a "home first" principle. Rather than keeping a patient in an acute hospital bed while a full assessment of their long-term care needs is carried out, the person is discharged to a more appropriate setting — their own home wherever possible, or a bedded setting such as a care home — and the detailed assessment of ongoing needs happens there instead. The logic is straightforward: hospital wards are for acute treatment, not assessment, and every extra day spent on a ward increases the risk of infection, deconditioning and loss of independence for an older patient.

Why Speed Matters: The Cost of a Delayed Transfer

The scale of the problem that D2A was designed to solve is significant. Delayed transfers of care rose by 31% between 2013 and 2015, consuming an estimated 1.15 million hospital bed days that could have gone to patients waiting for treatment. The human cost is just as stark: for a patient over 80, ten days in a hospital bed has been estimated to cause the equivalent of ten years of muscle ageing, driving exactly the kind of functional decline and deconditioning that our guide to preventing deconditioning and "PJ paralysis" sets out to reverse. A well-run discharge process protects the resident from this decline as much as it protects NHS bed capacity.

Where the Care Home Fits In

Under D2A, care homes are one of the recognised "step-down" or bedded intermediate care settings a person can move to instead of remaining on a ward. This support is usually short-term and time-limited — typically somewhere in the region of two to six weeks — before a fuller assessment decides whether the person needs ongoing residential or nursing care, can return home, or requires a different type of support altogether. Some areas use "trusted assessor" arrangements, where a nominated professional (often a discharge coordinator or a senior care home nurse) can assess and confirm a placement without waiting for multiple separate professionals to visit the ward, speeding up the whole process considerably.

A Practical Checklist for Accepting a Hospital Discharge

Before agreeing to accept a resident directly from hospital, care home staff should confirm:

• Discharge summary. A written summary of the hospital admission, diagnoses, and any changes to the resident's baseline presentation or mobility.
• Medication reconciliation. An up-to-date medication list (a "to take out" or TTO chart) that matches what will actually be administered, with any new or stopped medicines clearly flagged.
• Risk assessments. Current information on pressure ulcer risk, falls risk, swallowing/dysphagia status, and continence needs — conditions can change significantly during even a short hospital stay.
• Equipment needs. Confirmation of any equipment required (hoists, pressure-relieving mattresses, walking aids) and whether it will arrive with the resident or needs to be sourced separately.
• Communication with family. Family or next of kin informed of the admission date and any changes in the resident's condition or care needs.

Common Pitfalls

The most frequently reported problems are discharge summaries that arrive after the resident, medication charts that don't match what the hospital pharmacy actually dispensed, and discharges that happen late on a Friday afternoon with no way to query anything until Monday. Where possible, care homes should push back on discharges that arrive without the minimum information above, and build relationships with hospital discharge teams so that problems can be raised and fixed quickly rather than discovered after the fact. A robust pre-admission assessment process — checking what is actually known about a prospective resident before the day they arrive — reduces the number of nasty surprises considerably, whether the admission is coming from hospital or from the community.

Frequently Asked Questions

How long can Discharge to Assess support last? It's intended to be short-term and time-limited, typically a matter of weeks rather than months, while a fuller assessment of long-term needs is completed. It should never be treated as an automatic route into permanent residential care without that fuller assessment taking place.

What should we do if a resident arrives without a discharge summary? Contact the discharging ward or the hospital's discharge team immediately, document the gap clearly in the resident's notes, and escalate through your organisation's usual safeguarding or incident-reporting route if the missing information creates a safety risk.

Does a hospital discharge count as a full needs assessment? Not on its own. D2A is designed to move the assessment out of hospital, not skip it — the care home and community teams still need to carry out a proper assessment of the resident's ongoing needs once they've settled.

Getting hospital discharge right protects residents from the harm of a prolonged hospital stay while making sure care homes are never left managing a placement they don't have the information to support safely. For staff who want to build wider CPD around resident admissions and risk management, Learnsignal's CPD courses for care staff cover this alongside other core compliance topics.