Overview
Premature discharge without proper support increases safety risks and readmission rates. However, delayed discharge prolongs hospital stays, raises the risk of hospital-acquired infections, and hinders independent living, especially in older adults. Up to 10% of muscle strength can be lost within a week of immobility in hospital[1].
From admission, clear discharge expectations should be set, involving the multidisciplinary team, patient, family, and carers. Cognitive, functional, and social status must be assessed before and during hospitalisation, based on individual norms rather than general expectations.
Hospitals follow specific discharge policies, with assessments determining the level of post-hospital care required:
- Simple discharge: minimal or no additional care needed.
- Complex discharge: specialised care required, demanding a detailed care plan involving the patient.
A discharge summary is sent to the GP, detailing the admission, key test results, diagnoses, treatments, and future management.
Further information on discharge pathways, support services, and relevant team members is provided at the end of the page.
OSCE Tips and Scenarios
Possible scenarios
- Post-stroke: patient has weakness and swallowing difficulties, concerned about daily activities.
- Post-fall: patient fears falling again, affecting confidence in mobility.
- Post-COPD exacerbation: concerned about recurrence and prevention.
- Post-myocardial infarction: struggles with medication adherence and access.
- Caring for someone else: ready for discharge but worried about managing a dependent partner.
Tips for the station
- Assess patient understanding first: always ask what the patient knows before explaining. This lets you tailor explanations to their knowledge and identify other cues and concerns that need addressing.
- Know your limits: don’t promise something you can’t do. Always remember to consider if you need to involve seniors or other health professionals.
- Be aware of community support: you don’t need to know everything but understand the roles of GPs, district nurses, physiotherapists, pharmacists, and available services (meals on wheels, home railings, carers).
- Ensure a safe discharge: the aim is to ensure this patient can go home safely – can the patient move safely at home? Address their concerns systematically.
- Identify support needs systematically: discuss daily activities with the patient and offer support when needed (e.g. getting out of bed, bathing, cooking, shopping etc.)
- Use the discharge summary: guide the discussion with the summary, covering past events, current status, and future care.
- Encourage independence: don’t jump to offering 24/7 care when it may not be needed. Ask the patient how they’d feel about handling activities and encourage them to be independent where possible.
Common mistakes
- Over-focusing on one aspect: such as spending too long explaining the diagnosis. You should provide brief, but clear explanations based on concerns identified.
- Ignoring patient perspectives: always explore their background leading up to now, their viewpoints, and concerns.
- Ignoring expectations/poor negotiation: always explore the patient’s expectations, discuss realistic options, and offer negotiation. Some things may not be possible and may need further discussion with a senior.
- Lack of closure: conclude the conversation with a clear summary and plan moving forward, ensuring the patient understands.
- Jargon and monologuing: avoid one-sided conversations and invite the patient to ask questions. Only use terms the patient can understand.
- Inadequate responses to questions: answer questions clearly. If you are unsure, be honest and offer a solution to this (e.g. seeking advice from a colleague). Not doing so could risk confusion and dissatisfaction.
- Avoiding difficult topics: patients must understand risks to make informed decisions. For example, if there is a risk of death, the word ‘death’ must be said, not euphemisms (e.g. ‘passing away’).
- Over-reliance on seniors and leaflets: you should have a baseline level of understanding and be able to answer patients’ questions.
- Exceeding professional limits: do not offer to perform tasks or promise anything beyond your grade. Always remember to consider discussion with a senior.
Key Communication Skills
Explaining
- Confidentiality: if speaking to friends/relatives, only work with what they know. Avoid sharing new information unless you are certain that the patient has consented to this. If they push you, offer to explain the principles of confidentiality and the law.
- Never launch into explaining immediately: the goal isn’t to see how well you know a topic, nor should you try to tick boxes based on what you think the station is testing you on. Always use ideas, concerns, and expectations (ICE) to guide the consultation. Try to avoid forcing them all out at the start and address them as they arise.
- Always chunk and check: after each explanation, confirm understanding (e.g. “Does that make sense?” and “Is there anything else you’d like to ask about that part?”).
- Avoid medical jargon: use plain language (e.g. ‘underactive thyroid’ instead of ‘hypothyroidism’).
Empathy
- Empathise and offer appropriate reassurance: reflect the patient’s feelings and reassure them you’ll try your best, but don’t falsely reassure something you can’t guarantee. For example, for a patient worried about their diagnosis, you could say “It is natural to be worried about a new diagnosis, but we are here to help and address any concerns you might have”.
- Avoid collusion: validate emotions without taking sides. For example, if a patient is angry towards a colleague, you could say “I appreciate how this situation can make you feel that way”.
- Consider breaking bad news: always be careful to explore the patient’s background and understanding before accidentally delivering bad news they didn’t know. Remember that bad news isn’t always cancer and death.
Potential Ideas, Concerns, and Expectations
- “Have I actually had a heart attack?”
- “What was the treatment I had?”
- “Has this treatment sorted out the problem for good?”
- “What changes were made to my medications?”
- “Where will I get more medications from?”
- “I’m worried about taking these medications right”.
- “Is there any support for paying for these tablets?”
- “Will I have further tests in the future?”
- “Will my GP know what happened?”
- “What can I do to stop this happening again?”
- “What do I do if this happens again?”
Approach
Introduction
- Wash hands and introduce yourself with your full name and role.
- Confirm identify: the patient’s full name, date of birth, preferred name, or relation to a patient if this is a family member, friend, carer etc.
- Explain purpose and gain consent: “I understand you’d like to talk about going home?”
Background
Explore their background and understanding:
- Events so far: what has happened and how do they feel now?
- Understanding: what do they know about what’s happening?
- Ideas and concerns: is there anything they’d like to ask or are worried about?
- Expectations: what would they like from this conversation?
- Confirm conversation direction: “So you’d like to discuss your care and future support, is that right?”
If available, ask to see their discharge summary:
- Confirm its details: including past medical history, drug history, admission details, follow-up plans, medication changes etc.
Admission
Identify and address concerns about:
- Going home: how do they feel about going home? Are they worried about returning to their usual lifestyle?
- Admission events: any questions about tests, diagnoses, treatments etc.?
- Immediate plans: any questions about getting home, transport, where they need to go, discharge logistics etc.?
- Future care: do they have any questions about their follow-up, medications, support etc.?
Social circumstances
Explore their support system:
- Living situation: what type of home do they live in? (e.g. bungalow, flat, house, care home etc.)
- Independence: are they usually independent, such as getting around the house and up the stairs?
- Who’s at home? – do they live with anyone else that could provide help?
Explore potential caring responsibilities – do they look after anyone?
- Their needs: what are the needs of the person they’re looking after? Talk through activities of daily living and how the patient feels about continuing this post-discharge.
- Are they managing? – do they need any help with this?
- Who’s taken care of their home during their admission? – has everything been looked after during the admission? Do they have any children or dependents (this could raise potential safeguarding concerns)?
Lifestyle
Explore their lifestyle and health:
- Past medical history, drug history, allergies, and family history
- Occupation: do they work? Would this impact their work? Do they need a sick note?
- Driving: do they drive and are they allowed to continue? (e.g. post-seizure)
- Substance use: do they smoke, drink alcohol, or use illicit drugs? Would they like any help with this?
If any concerns arise, suggest (but do not promise) realistic solutions:
- You should mention that you’ll discuss these with relevant colleagues (e.g. social workers, physiotherapists etc.)
Medications
Explore the clinical implications of their medication:
- Any concerns? – some stations may instruct actors to reply with “The pharmacist has already discussed this with me”. This is a cue to indicate that this may not need in-depth discussion.
- Indications: do they know what the medication is and why they’re taking it?
- Administration: do they know how and when to take it?
- Side effects, safety-netting: do they know about its important side effects and when to seek help if they arise?
Explore the logistical implications of their medication:
- Adherence: would they have any problems taking the medication? Some solutions include:
- For complex regimes: dosette boxes/blister packs may be used.
- Formulation changes: some tablets could be changed to other forms, such as solutions, for patients who may struggle to swallow them.
- Obtaining medication: do they know where to get their medication?
- Costs: can they cover the costs of their medications?
- Renewal: do they know where to renew their prescription? Hospitals usually give a 7-day supply post-discharge. Inform the patient to make an appointment with their GP for repeat prescriptions.
Follow-up
Explore future care:
- Understanding: do they understand the next steps? The discharge letter is sent to both the GP and the patient.
- Follow-ups: do they have outpatient appointments? Would they be able to attend these?
- Patients are sent a letter with hospital outpatient follow-ups and should get in touch if they don’t hear back.
- Contacts: do they need to contact any healthcare workers? Give safety-netting advice, suggesting their GP, 111, or A&E if needed.
Lifestyle and self-care measures
- Preventing problem recurrence/worsening: could you offer support with smoking cessation, reducing alcohol intake, and taking medication?
- Safety netting: give clear instructions on what to look out for and what to do. Avoid being vague (e.g. do not say “If you feel worse, come back”, tell them specific scenarios and where to go).
Concluding
Summarise and clarify
- Confirm what has been said: “So to summarise, we have discussed what happens after your discharge and you’d like to get in touch with your GP about further support. Is that correct?”
Check understanding
- ICE: has everything been acknowledged?
- Invite further questions: anything else to discuss?
- How they feel now: do they feel okay with the plan?
Finishing
- Confirm follow-up: if relevant, ensure their follow-up is in place.
- Offer additional resources: such as leaflets, early follow-up, relevant contacts etc.
- Thank the patient and document the discussion.
Background Notes
Intermediate care
Social care describes support for personal care needs, including carers, home adaptations, alarms, meals on wheels, and housing services (e.g. supported living, care homes).
Intermediate care describes short-term home/community-based services post-discharge to aid recovery and independence, reducing re-admission. Types include:
- Reablement: helps regain confidence in daily living skills (e.g. cooking, washing) for 1-6 weeks if eligible[2].
- Rehabilitation: supports functional recovery after illness/injury[3].
- Crisis response: short-term (hours) urgent care at home/care home to prevent admission.
- Community-based: home-based assessment and interventions.
- Bed-based: care in a hospital, residential home, nursing home, or intermediate care unit [4, 5].
Respite Care
Provides temporary relief for carers based on assessment and eligibility. Types include:
- Family/friends: temporarily assisting at home or hosting the patient.
- Day care centres: social engagement via activities, crafts, games (run by councils/charities).
- Homecare: paid carers offering regular short-term care.
- Short care home stays: temporary accommodation at care homes if available. Depends on what local nursing homes and residential care homes can offer.
- Respite holidays: breaks for patients and carers (e.g. MindforYou provides support for holidays for people with dementia and their carers. Family Fund has grants for people with a low-income who care for a child with a disability/serious illness).
- Sitting services: volunteers providing companionship for a few hours. Run by charities and often free.
- Emergency respite: identifying backup contacts (e.g. family, friends) in case of carer emergencies.
Funding options:
- Council-funded: depends on needs and carer assessments.
- Charities: organisations like Carers Trust, Turn2us offer grants.
- Self-funded[6].
Glossary
- Care transfer hub: single access point coordinating post-discharge care across health, social care, and housing.
- Criteria to reside: a set of principles that help determine whether a patient meets the criteria to reside in a hospital bed (e.g. IV medication, NEWS score).
- Discharge to assess: new/additional care needs are provided and assessments of long-term needs are fully completed once the patient is out of hospital and reaches a point of recovery and stability.
- Home first: an approach that sets peoples’ default discharge approach to their home. If this is not possible, then alternative pathways are considered (discussed below)[3].
Living support
- Care home: provides accommodation and personal care for those unable to manage independently (e.g. old age, disability). Types:
- Residential care home: 24/7 staff for daily tasks (e.g. dressing, medications).
- Nursing home: qualified nurses available 24/7, providing medical treatments[7].
- Hospice: end-of-life care for those with terminal illnesses nearing the end of life[8].
- Community hospital: rehabilitation and basic nursing without on-site doctors. Patients are transferred back to hospital if emergencies arise.
- Independent/sheltered living: flats/bungalows for older people to live in independently with emergency call systems, daily check-ins.
- Supported/assisted living: flats with staff who assist with daily tasks (e.g. shopping, laundry).
- Own home with care package: discharged with home care support (e.g. carers visiting to provide support).
Healthcare Roles
- Occupational therapists (OTs): assess and recommend mobility aids, home adaptations, care packages.
- Social workers: evaluate eligibility for NHS-funded care based on OT recommendations.
- Dieticians: manage nutrition-related issues.
- Speech and language therapists (SALT): assess and treat speech, language, swallowing disorders.
- Pharmacists: review medications, adherence, and safety.
- Care home representatives: assess care home admission suitability.
Support with Daily Activities
NHS-funded adaptations are offered based on an assessment of needs and if they are below a certain cost threshold. These may include:
- Mobility: walking aids, stairs rails, stairlifts, ramps.
- Toileting/showering: grab rails, shower stools, non-slip mats.
- Self-care: modified tools for dressing, eating, personal hygiene.
- Shopping and meals: online shopping, meals on wheels, family help.
- Medication adherence: dosette boxes, blister packs, nurse support.
- Incontinence: managed with continence nurse input and pads.
Discharge Pathways
A discharge pathway defines a patient’s post-hospital route:
- Pathway 0: simple discharge to home/temporary accommodation without new health/social care needs.
- Support involves self-management, and signposting to community services, or charities.
- If relevant, also involves restarting a pre-existing care home/care home package at the same level of care that was paused during admission.
- Pathway 1: discharge home with support, coordinated by care transfer hub. Can involve intermediate care:
- May include short-term home-based intermediate care for rehabilitation/reablement.
- If relevant, may involve restarting a care home package at the same level as a pre-existing package that had ended.
- May involve long-term care and support at home after a period of intermediate care in the community if deemed necessary after an assessment.
- Pathway 2: discharge to a community-based bed (e.g. rehab, reablement, end-of-life care). This may include:
- Short-term bed-based intermediate care for rehabilitation, reablement, and recovery
- Provision of end of life care alongside intermediate care where applicable
- Pathway 3: discharge to care home or hospice for complex care needs. This may include:
- Placement in a care home for assessing long-term and ongoing needs in relation to permanent placement.
Fit Notes
Fit notes (Statements of Fitness for Work) confirm a patient’s ability to work:
- ≤7 days: no formal note required; employer may request self-certification.
- >7 days: requires fit note from a GP, nurse, OT, physiotherapist, or pharmacist.
Possible adjustments include:
- Gradual return to work
- Temporary change in hours or duties
- Additional job support (e.g. avoiding lifting for back pain)
No are no charges for standard fit notes, but private certificates may be needed for repeated <7-day absences, which may incur a fee.
