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Executive Summary

  • The person’s individualised goals should be central to the care and support to be provided, with self care being the basis of all actions.
  • Older people with high levels of dependency and complex health and social care needs should always be considered as transferring from one part of a continuum to another rather than being discharged.
  • Person centred, multidisciplinary assessment and care management should start at the earliest opportunity and where possible at referral.
  • A multilayered approach to assessment and rehabilitation co-ordinated by the multidisciplinary team and formally reviewed at pre determined intervals is essential
  • The care environment should be dictated by the needs and choices of the individual whenever appropriate
  • Multi agency involvement in complex packages of care is becoming the norm and communication needs to be robust in order to reduce risks

1. Introduction

This paper outlines some of the key issues in regard to the transfer of care for frail older people between providers, with a particular focus on the person returning home. It aims to identify core principles which should be present regardless of local variations in service provision and directs the reader to a number of resources available to support their processes and service development.

2. Background

Changes to health and social care delivery over the last 10 years have seen a move to greater provision of complex care in community settings and a wide variety of services aimed at preventing inappropriate acute hospital admission. Proactive management of the care of people with long term conditions, maintaining the frail older persons at home to prevent early admission to long term care, and early facilitated discharge from hospital are the focus for all health and social care providers. 

Ensuring that assessment and care is provided at the right time, in the right place by the right person, maximises the use of resources, supports personal choice for the individual and develops a person centred approach.  However, with the plethora of options now available it does mean that episodes of care will often not start and stop neatly within a service or a care environment. Therefore provision of health care and social support for older people with frailty and or long term conditions should be seen as a transfer between the different services, and a lead professional should be identified to co-ordinate the care services being provided. At a minimum, this cohort within the population will be receiving services from the primary care team but frequently a range of statutory, private and voluntary providers will be involved. Working with the individual, carers and significant others in the persons support/care network, is crucial to ensuring seamless services, whilst always aiming to avoid repetition, inappropriate treatment, gaps in treatment and harmful outcomes.

The person should always be at the centre of the management plan and be the holder of their information whenever possible. However the nature of need in this population means they often require complex multi-provider care and support which leaves them vulnerable to information overload and misunderstanding. To ensure safe handovers there is a requirement that professionals and organisations have attitudes, approaches and processes which render the complications of multiple provider involvement as invisible to the receiver of the care.

Health and Social care providers increasingly need to ensure integrated pathway management building flexibility in its processes to meet the public’s expectations and to uphold the commitment of the NHS Constitution.1 Planning and communication at the point of transfer of care is critical in delivering safe, appropriate support leading to enhanced patient experience.

3.  Elements important to the effective transfer of care

3.1 Self – care
Individualised care plans should be developed with patients/clients to ensure proactive management of the person’s condition and should include the principles of self care. Therefore, empowering individuals and families, to manage their own needs through information and support. In turn this supports safe use of multiple providers. Within every consultation, information should be given to the individual and or their carer enabling them to know what to expect and therefore challenge if it does not happen. “Self care by definition is led, owned and done by the people themselves….” 2, 3.

3.2 Communication
Good communication is the link to safe transfer of care. To ensure good communication there is a need for professionals and organisations to develop an understanding of each others role in the process improve their personal skills and involve the right people, breaking down professional and organisational barriers and tribalism’s where it exists. There are a range of requirements on organisations to deliver care differently and increasingly commissioners of health and social care will require evidence of integrated working practices.

Development of shared assessment documentation enables treatment/management plans to be more informed. Personalised care plans/advance care planning can support the communication process between multiple agencies and gives control to the individual regarding their own information4,5. It is important that any Not for Resuscitation decisions should also be part of the transfer information. Work across NHS South Central has resulted in all health providers agreeing a process and identical documentation.6 Information regarding any infection risks, for example MRSA, needs to be included when transferring the patient 7

3.3 Multidisciplinary working
Regardless of the care setting, frail older people and those with long term conditions should have access to a multidisciplinary assessment to identify their needs holistically. Increasingly, the professionals and skills needed to support this process will involve several organisations and/or be sited across multiple locations.

For best practice pathways to exist, engagement with commissioning in the development of these pathways needs to be supported by clinicians active at the front line of services.  Responsibility lies with each and every practitioner regardless of their employer to share relevant clinical information with others. Development of CAF8 and SSA9 aims to support this process in a more consistent and structure way.

3.4 Environments of care
The environment for the care to be provided should be based on the needs of the individual requiring the care. Acute admission may support a rapid assessment particularly when multiple investigations are required over a short period of time with a responsive immediate requirement to act on results, or where the acuteness or instability of the condition requires intensive support. However rapid assessment can also be provided in other settings such as day hospitals/units, in community hospitals, or in the person’s own home by rapid response teams.  Local providers will continue to need to develop a range of options which reflect cost effective use of resources and skills and support patient choice. 4, 10, 11, 12 13

3.5 Medications reconciliation
Many medication errors occur at ‘handover points.14 this is an important area for risk management. Poor communication, lack of confirmed information and an individual’s poor knowledge regarding their medication can impact on outcomes. Unintentional variance between pre admission and on admission to hospital medication prescriptions is reported to be between 30-70%.15 Often individuals are transferred between health and social care environments when treatment regimes are still being stabilised, for example continuation of IV antibiotic therapy, anticoagulant therapy16 and chemotherapy in the community. A robust process should be in place that supports the patient and their carers to understand the medications they are taking and the intended course, as well as clear handing over to the relevant professionals all the appropriate information to continue to administer, monitoring and evaluate effects.

3.6 Mental Capacity – Deprivation of Liberty – Safeguarding
The mental capacity Act (MCA) 2005 17 in England and Wales, and Adults with Incapacity (2000) in Scotland,18 was developed to protect people without capacity from health and social care bodies developing care plans without their involvement and to ensure arrangements are tailored to meet the individual’s best interests. In cases where capacity is in doubt application of the code(s) of practice is a legally requirement. Further guidance is available from another BGS good practice guide.

3.7 Entitlements to continuing care assessment
Recently published revision of the National Framework for NHS Continuing Health Care and Funded Nursing Care (England and Wales only)19, needs to be considered in the transfer of care planning process. Delays in transfer should not occur because of the increased requirements to screen individuals against the eligibility criteria before requesting local authority funding. Therefore actively building in sign posts to assessment within the transfer planning documents should ensure timely compliance. The criteria for NHS Continuing Health Care was also recently reviewed in Scotland 20

3.8 Person held budgets/Direct Payments
Underway at present is reform of the provision and funding of social care as identified in recent consultations and government white papers. There is a perceived need to empower individuals in the management and commissioning of their own care.  The impact that this may have on the transfer of care process for people with complex care needs is not yet known but policy and practice across health and social care will need to be constantly and consistently reviewed to ensure that timely and integrated care happens at care transfers21, 22 23.

3.9 Carer support
Increasingly the implementation of policies which support people with high dependency and complex needs living in community settings results in increased responsibility falling on carers. Without appropriate information and access to emotional, practical and financial support, the health and wellbeing of carers can be adversely affected and care packages fail. During transfer of care planning the voice of the carers needs to be listened too. Involvement at every stage is paramount and should not be an afterthought. Each carer is legally entitled to an assessment of their personal needs. 24 25

The national carers’ strategy in Scotland is currently being reviewed 26

3.10 Provision of Equipment
The safe transfer home of an individual will often require a home assessment and the provision of equipment. Timely and appropriate assessments by occupational therapists can reduce risk and enable the maintenance of independent living. Involvement of occupational therapists should commence early on, in planning, particularly to ensure every opportunity is given for the individual to return home.  Most areas now have joint arrangement between health and social care for the provision of community equipment and delivery services which facilitate timely discharge to home.

3.11 Organisational Responsibilities
Each organisation delivering health and social care to frail older adults needs to ensure that care pathways deliver person centred, cost effective support, aimed at reduced inappropriate acute hospital admission and readmission, facilitated early discharge and reduction of long term care placement.

All staff need to understand their role in transfer / discharge of care planning. Internal and external, cross organisational policies and procedures need to facilitate this process.

Patient experience and effectiveness of care interventions on patient outcome need to be audited to ensure that new ways of working deliver the desired results.

Practical information and resources which can support staff to manage the transfer of care activity have been produced by:
The Institute of Innovation and Improvement through its productive series. 27

The DH (England) has re launched clear and practical guidance on the practice of discharge and transfer of care management.28

The Welsh Assembly has published a practical guide to effective discharge. 29

The Scottish Government has published a best practice template for admission, transfer and discharge. 30

4.  Conclusion

The discharge or transfer of care of an older adult with complex health and social needs requires the experience and skills of several professionals from a range of different organisations.  Without careful coordination this process can disintegrate to the detriment of the patient and their family. 


  1. DH (2009) revised (2010) The Handbook to the NHS Constitution
  2. DH (2006) Supporting people with long term conditions to self care – A guide to developing local strategies and good practice
  3. DH (2005) self Care – A Real Choice, Self care support – A real choice
  4. Scottish Government (2009) Long Term Conditions Collaborative Improving Complex Care NHS Scotland
  5. DH (2009) Supporting people with Long Term Conditions Commissioning Personalised Care Planning: A guide for commissioners DH, London
  6. NHS South Central (2009) Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy
  7. DH (2009) The Health and Social Care Act 2008 Code of Practice for health and adult social care on the prevention and control of infections and related guidance
  8. DH (2009) Common assessment framework for adults. A consultation on proposals to improve information sharing around multi-disciplinary assessment and care planning. DH. London
  9. Scottish Government (2005) Guidance for local managers to implement the SSA-IoRN
  10. DH (2007) A Recipe for Care –Not a Single Ingredient Clinical case for change: Report by Professor Ian Philp, National Director for Older People
  11. DH (2009) NHS 2010-2015: From Good to Great. Preventative, People – Centred, Productive.
  12. Personal Social Services research unit for Department of Health (2010) National evaluation of partnerships for Older Peoples Projects: Final report
  13. DH (2009) Intermediate Care – Halfway home: Undated Guidance for the NHS and Local Authorities. DH
  14. Smith J (2004) Building a Safer NHS for Patients: Improving Medication Safety. DH
  15. NICE (2007) Technical patient safety solutions for medicines reconciliation on admission of adults to hospital
  16. NPSA (2007) Actions that can make anticoagulant therapy safer. Alert and other information
  17. Ministry of Justice (2005) Mental Capacity Act 2005
  18. Adults with Incapacity Act (2000)
  19. DH (2007) The National Framework for NHS Continuing Care and NHS-Funded Nursing Care. DH (revised 2009)
  20. The Scottish Government (2008) CEL 6 (2008) NHS Continuing Healthcare. Edinburgh
  21. HM Government (2007) Putting People First: a shared vision and commitment to the transformation of Adult Social Care
  22. DH (2010) Guidance on Eligibility Criteria for Adult Social Care DH
  23. 2007 no. 458 social work The Community Care (Direct Payments) (Scotland) Amendment Regulations 2007
  24. Carers and Disabled Children Act 2000
  25. Carers at the heart of 21st century families and communities: a caring system on your side, a life of your own
  26. Scottish Executive (1999) Strategy for Carers in Scotland. Edinburgh
  27. Institute of Innovation and Improvement – Productive Series – Productive ward modules
  28. DH (2010) Ready to Go? Planning the discharge and transfer of patients from hospital and intermediate care. DH
  29. Welsh Assembly Government (2008) Passing the baton: A practical Guide to effective discharge planning. Welsh Assembly Government
  30. Scottish Government (2009) Admission, Transfer and Discharge Protocols for Patients in Scotland. Edinburgh

Further reading

DH (2000) No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults for abuse. DH and Home (review and update pending)

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