Discharge to Assess (Home First)
Amendment
In February 2024, this chapter was reviewed and refreshed, including the addition of several national resources.
Defined by NHS England, Discharge to Assess (also referred to as Home First) is a collaborative model of care “where people who are clinically optimised and do not require an acute hospital bed, but may still require care services, are provided with short-term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person”.
Everyone should have the opportunity to recover and rehabilitate at home (wherever possible) before their long-term health and care needs and options are assessed and agreed. To this end, services that provide support with recuperation, recovery, ongoing rehabilitation, or reablement are often a key part of the Discharge to Assess model.
Professionals from all relevant services (such as health, social care, housing and the voluntary sector), should work together so that, other than in exceptional circumstances, no one should transfer permanently and directly into a care home for the first time following an acute hospital admission.
At all times, practitioners should refer to the most recent government guidance and any local protocols and pathways to ensure the model is applied as intended.
Department of Health and Social Care: Hospital discharge and community support guidance.
Hospital Discharge and Community Support: Staff Action Care – Adult Social Care Teams.
NICE guideline NG27: Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
NHS England: Quick guides to support health and social care systems.
When a person is medically optimised for discharge, a Discharge Planning Nurse (DPN) will make a referral to SPOC which should be added to LAS upon receipt.
In the referral, the DPN will recommend which of the available discharge pathways they feel is most appropriate. This recommendation should be considered, but does not have to be arranged if it does not appear to be the best option for the person. A home-first option should always be considered.
The above process will be changing, hopefully by Autumn 2023. At this point practitioners and DPN’s will return to being ward aligned and able to respond without the need for a ward referral.
Pathway 1 – people returning to their own home
In pathway 1, the Home First Hospital Discharge Team would not see the person, unless the DPN has requested involvement due to safeguarding concerns or risk.
Options for discharge:
- Restart of existing HISS package/extra care. No review complete post-discharge;
- Increase of existing HISS package/extra care- Named/allocated worker would review increase. If no allocated/named worker then HDT will review;
- New package with HICSS (free for up to 6 weeks) Trusted assessor review post-discharge;
- Ward may make referral to ACTs for follow up too.
Pathway 2 – people who require rehabilitation before returning home
In pathway 2, the Home First Hospital Discharge Team would not see the person prior to discharge, but will work with them during the period or rehabilitation. Following this period, the case would be transferred to another team.
Options for discharge:
- Haven Court bed-based rehab.
- Thomas Bell House.
Pathway 2 is free for the person for up to 6 weeks. After this, it is chargeable at respite rates.
Pathway 3 – people who require a short-term care home placement
Pathway 3 cannot be arranged without the involvement of the Home First Hospital Discharge Team, who need to complete a C2 (and Mental Capacity Act if appropriate) prior to discharge.
Note: The above can be carried out by the Neighbourhood Team if there is already a named/allocated worker.
As part of the C2, the appropriateness of pathway 2 should be considered or reconsidered if the person appears to have rehabilitation potential. Whether or not the person could go back home should also be considered.
Options for discharge:
- Wellbeing flat at Blenkinsopp or Clasper Court. These are in the dementia area therefore behind locked door. If the person does not have capacity COP/DOLs screening tool is to be completed. Free for up to 6 weeks. Please see guidance around these flats. Ongoing review during 6 weeks;
- 24-hour live-in carer- Springfield Healthcare provide this service for 2 weeks only. Free during this time. Criteria for this service- please see guidance. Ongoing review, plan has to be ready at end of 2 weeks- i.e., move to HICSS, move to wellbeing flat, move to care home;
- Residential or EMI residential care home. Chargeable from point of discharge. Review around 2 weeks post-discharge;
- Nursing or Nursing EMI care home- ward will need to complete a nursing proforma and CHC nurse has to agree evidence of nursing needs. Chargeable from point of discharge. DST will be held after discharge and attended by neighbourhood team.
Pathway 3 Return – person returning to an existing care home placement with no changes
In pathway 3 return, the Home First Hospital Discharge Team would not see the person, unless the DPN has requested involvement due to safeguarding concerns or risk.
There is information available for residents about our discharge to assess pathway and services. This can be found in the local resources area.
Last Updated: August 19, 2024
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