9.1 Continuity of Care, Discharge Planning & Referrals

Continuity of Care, Discharge Planning & Community Referrals

Continuity of care is a fundamental pillar of modern nursing practice under Platform 7 of the NMC Standards of Proficiency for Registered Nurses (2018). Safe care transition requires structured communication, robust interprofessional collaboration, and meticulous post-discharge planning. When transitions between acute hospital care, intermediate rehabilitation, and community settings are poorly coordinated, patients face heightened risks of medication errors, clinical deterioration, readmission, and Delayed Transfer of Care (DTOC).

+-----------------------------------------------------------------------------------+
|                        ADMISSION & DISCHARGE TIMELINE                              |
+-----------------------------------+-----------------------------------------------+
| Admission Assessment (Day 1)      |  - Identify baseline function & support       |
|                                   |  - Highlight complex discharge triggers       |
+-----------------------------------+-----------------------------------------------+
| Multidisciplinary Care (Ongoing)  |  - Coordinate OT, PT, Social Care, Nursing    |
|                                   |  - Complete CHC screening / DST if indicated  |
+-----------------------------------+-----------------------------------------------+
| Pre-Discharge (24-48 hours prior) |  - Order TTO medications & equipment          |
|                                   |  - Confirm transport & carer arrangements     |
+-----------------------------------+-----------------------------------------------+
| Day of Discharge                  |  - Complete SBAR transfer handover            |
|                                   |  - Issue electronic summary to GP (<24 hrs)   |
+-----------------------------------+-----------------------------------------------+

Proactive Discharge Planning starting at Admission

Discharge planning must never be treated as a final-day administrative task. Best practice guidelines from NICE (NG27: Transition between inpatient hospital settings and community or care home settings) mandate that discharge planning begins at the point of initial admission or pre-admission assessment for elective cases.

Core Objectives of Early Discharge Assessment

1. Establishing Baseline Function: Assessing the patient's pre-admission cognitive status, physical mobility, activities of daily living (ADLs), home environment, and existing informal or formal care packages.
2. Identifying Complex Discharge Triggers: Early identification of factors that complicate community transition, including severe frailty, cognitive impairment, palliative care needs, homelessness, safeguarding concerns, or major home equipment requirements (e.g., hospital beds, hoists).
3. Establishing Estimated Date of Discharge (EDD): Setting a realistic EDD within 24–48 hours of admission gives the Multidisciplinary Team (MDT), patient, and family a shared target for recovery milestone tracking.
4. Preventing Delayed Transfers of Care (DTOC): Minimizing non-clinical bed days where a patient is declared Medically Fit for Discharge (MFFD) or medically optimized, but remains hospitalized due to delayed social care funding, care home placements, or equipment delivery.

Multidisciplinary Team (MDT) Roles in Discharge

• Registered Nurse: Acts as the primary discharge coordinator, synthesizing clinical progress, conducting ongoing risk assessments (e.g., Waterlow scale, MUST nutritional tool, moving and handling), managing discharge medication reconciliation, and making community referrals.
• Occupational Therapist (OT): Evaluates functional independence, conducts environmental home assessments, prescribes assistive devices, and arranges home adaptations.
• Physiotherapist (PT): Assesses gait, balance, transfer safety, and devises rehabilitation plans to maximize physical independence prior to transfer.
• Hospital Social Worker: Assesses social care eligibility under the Care Act 2014, coordinates domiciliary care packages, arranges care home placements, and conducts financial assessments.
• Discharge Coordinator / Navigator: Facilitates communication between hospital wards, local authority social services, continuing care teams, and voluntary sector agencies.

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Structured Handovers & Transfer Documentation

Clinical handovers represent high-risk transitions in patient care. Inaccurate or incomplete information transfer can lead to missed red-flag observations, therapeutic delays, and adverse drug events. The NMC Code mandates clear, transparent, and accurate communication during all transfers of care.

The SBAR Handover Tool

The SBAR (Situation, Background, Assessment, Recommendation) framework is the gold-standard standardized communication tool recommended by the NHS National Patient Safety Agency (NPSA).

Discharge Summaries & Medication Reconciliation

• Electronic Discharge Summary Transmission: The hospital must transmit a comprehensive discharge summary to the patient's General Practitioner (GP) and receiving community nursing teams within 24 hours of discharge.
• Content Requirements: Primary admission diagnosis, hospital course, diagnostic test results, procedures performed, secondary diagnoses, explicit discharge medication list, stopped or altered long-term medications with clinical rationale, required follow-up blood tests or clinic appointments, and clear emergency red-flag instructions for the patient.
• To Take Out (TTO) / Discharge Medications: The nurse must reconcile TTO medications against admission medicines and acute ward prescriptions, ensuring the patient or carer receives clear verbal and written instructions regarding drug names, indications, dosages, frequencies, and potential side effects.

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Post-Discharge Support, Continuing Healthcare & Community Referrals

NHS Continuing Healthcare (CHC) vs. NHS-Funded Nursing Care (FNC)

• NHS Continuing Healthcare (CHC): A package of ongoing care arranged and funded solely by the NHS for individuals outside hospital who have been assessed as having a "Primary Health Need". CHC covers the full cost of care in any setting, including the person's own home or a care home. Eligibility is not determined by disease diagnosis, but by a detailed multidisciplinary assessment using the national Decision Support Tool (DST) across 12 care domains (e.g., behavior, cognition, mobility, nutrition, skin integrity, breathing).
• NHS-Funded Nursing Care (FNC): A flat-rate financial contribution paid directly by the NHS to registered nursing care homes to cover the cost of care provided by a registered nurse for residents who do not qualify for full CHC but require registered nursing input.

Intermediate Care & Reablement Pathways

Intermediate care encompasses short-term, targeted interventions designed to restore independence, prevent avoidable acute hospital admissions, and facilitate timely hospital discharge:

1. Step-Down Care: Rehabilitation provided in a community hospital, residential reablement unit, or home setting for patients leaving acute hospital who require temporary recovery support before returning to baseline independent living.
2. Step-Up Care: Crisis response and short-term community intervention arranged to prevent an acute hospital admission when a patient experiences a temporary health decline.
3. Reablement Duration: Intermediate care services are free of charge at the point of delivery for a maximum period of up to 6 weeks.

Community Nursing Referrals

• District Nursing Service: Accepts referrals for housebound patients requiring complex wound care, leg ulcer management, administration of complex injectables (e.g., insulin, palliative subcutaneous infusions via McKinley T34 syringe driver), enteral feeding care, urinary catheter management, and bowel care.
• Specialist Community Teams: Referral pathways to Specialist Palliative Care Teams, Community Heart Failure Nurses, Respiratory/COPD Teams, Tissue Viability Nurses, and Community Mental Health Teams (CMHT).