COPDNICE has published guidance aimed at supporting people with social care needs to leave hospital in a timely and coordinated way. The guidance will help to reduce the number of people returning hospital unnecessarily, ensuring they receive the continuity of care they need when they return to their communities.

The recommendation comes from NICE’s latest social care guideline which aims to improve the transition between inpatient hospital settings and community or care settings for adults with social care needs.

Delays in the discharge of patients place a huge burden on the NHS. Figures from NHS England show that more than a million hospital days were lost due to delayed discharges over the past year. In September, 5,247 patients were delayed from being discharged, which is the highest figure so far in 2015.

Ensuring people also receive the most appropriate services when they are discharged from hospital also has a crucial effect on a person's wellbeing. It can speed up their recovery and ensure they are not readmitted because they are not receiving the right support at home.

The new guideline aims to ensure people with social care needs who need hospital treatment get the support they need to leave hospital in a timely manner. The guideline will also help to avoid repeated hospital stays.

NICE recommends that a single health or social care practitioner should be made responsible for coordinating a person’s discharge. The discharge coordinator should be the central point of contact for health and social care practitioners, the person and their family during discharge planning. Health and social care organisations should agree clear discharge planning protocols. The discharge coordinatior can be a member of the hospital or a designated discharge coordinated post can be created for this.

It also says that the coordinator should be selected according to the person’s care and support needs, and that a named replacement should always cover their absence. Furthermore, while planning for discharge, the discharge coordinator should share assessments and updates on the person’s health status, including medicines information, with both hospital and community-based teams. 

In addition, the guideline calls for continuity of care for people being transferred from hospital, and particularly for older people who may be confused or who have dementia.  Hospitals should ensure that any pressure to make beds available does not result in unplanned and uncoordinated discharges. Hospital and community teams should work together to tackle factors that could prevent a safe and timely transfer of care from hospital.

Kathryn Smith, Director of Operations at Alzheimer's Society and NICE guidance development group chair, said: 'Timely and appropriate discharge from hospital is essential to achieving high-quality, seamless care that's right for the individual. A stay in hospital away from familiar surroundings can be a very stressful time for anyone, particularly people living with dementia. Plans for discharge should be made with the individual to ensure that they are going to the place that's right for them – whether that's home or residential care. Effective planning should ensure that discharge is safe and at the appropriate time, for example during the week, when it may be easier to arrange care. We encourage comprehensive and specialist assessment of complex needs; close communication between everyone involved in the individual's care; and that discharge is supported through social care and reablement, where needed.

'Nearly all of the 850,000 people living with dementia in the UK will require care and support from both the NHS and social care system at some point in their lives – people with dementia account for around 3.2 million hospital bed days per year. We hope that this new guidance will support the health and social care system to provide continuous care that's tailored to the individual, wherever they are.'