This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people’s experience of admission to, and discharge from, hospital by better coordination of health and social care services.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
The guideline includes recommendations on:

person-centred care and communication and information sharing
before admission to hospital including developing a care plan and explaining what type of care the person might receive
admission to hospital including the establishment of a hospital-based multi-disciplinary team
during hospital stay including recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge
discharge from hospital including the role of the discharge coordinator
supporting infrastructure
training and development for people involved in the hospital discharge process.
Who is it for?
The guideline is for health and social care practitioners; health and social care providers; commissioners; service users and their carers (including people who purchase their own care).