Discharge to Assess

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.

Discharge to assess (D2A) can be used in the hospital to support people to return home when they have been assessed as medically fit to do so and a referral is made to the hospital team.  The practitioner working with the person will carry out an assessment with the person, their family and/or friends where appropriate and liaise with those professionals who have been involved in their care.

The practitioner will then complete a discharge to assess support plan and arrange for necessary services to be put in place to allow the person to be discharged home safely.

Support put in place via discharge to assess is funded by health for four weeks. It is important that the practitioner provides the person and their family with information about charging for services and are informed about the Financial Assessment. It is important that they are aware that once the D2A period has ended they could be charged for their care.

It is also important to ensure that the person is informed that any services that are put in place are for a short-term period, the package will be reviewed in 4 weeks and could change following this.

A referral will be made by the hospital social worker to one of the community teams for follow up at the point of discharge, that team then needs to schedule the case for a review.

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