Discharge to Assess and Intermediate Care
Intermediate care is an NHS and Social Care programme of active rehabilitation.
The service is non means tested.
The maximum length of stay in intermediate care settings is expected to be up to 6 weeks but may be shorter depending upon how people recover – this needs to be clearly communicated to the person and/or their family/carer. This period of up to 6 weeks is referred to as the ‘reablement period’.
There is no cost to individuals for this service for the duration of the reablement period.
Further guidance regarding funding after a reablement period is available in the Local Resources section.
Guidance setting out how NHS Bodies and local authorities can plan and deliver hospital discharge is subject to change nationally, regionally and locally.
Latest national guidance is available via: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)
Somerset’s Hospital Interface Service’s Operational processes and other relevant supporting information can be found in the Local Resources section.
People should be supported to be discharged to the right place, at the right time and with the right support that maximises their independence and leads to the best possible sustainable solutions.
Planning for discharge from hospital should begin on admission. Where people are undergoing elective procedures, this planning should start pre-admissions with plans reviewed before discharge. This will enable the person and their family or carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs.
Decisions to refer to Somerset’s Intermediate Care service should be influenced by the views of the person and the multi-disciplinary team.
The discharge hub considers whether the person can:
- Return to their normal place of residence with no additional support (Pathway 0);
- Return to their normal place of residence with time limited support (D2A/Home First/Community & Voluntary sector/increase in current package of care);
- Go to another bedded facility for assessment and reablement on a time limited basis.
The person must be involved in discussions around discharge planning.
Once this decision has been made, the Discharge Hub will alert the Somerset Hub for Coordinating Care (SHCC), which coordinates intermediate care arrangements.
- D2A D2Arequests@SomersetFT.nhs.uk;
- Bed requests BedRequests@SomersetFT.nhs.uk;
- Somerset Hub for Coordinating Care 01749 836700.
Under the 'discharge to assess', 'home first' approach to hospital discharge, the majority of people are expected to go home [to their usual place of residence] following discharge. This model [which you may hear referred to as 'D2A'] is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed. An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs.
Once individuals have received the maximum benefit from the service, the team will discuss discharge planning arrangements. Hopefully this will be a return home.
People may receive a financial assessment if they require ongoing care and they may be required to pay a contribution towards their care or pay for all of it depending on the outcome of that assessment.
Intermediate care beds must be vacated as soon as possible to facilitate further flow from the hospital.
If an individual needs care to support them at home, they may have to move elsewhere whilst care is arranged via the Care Sourcing team due to demand and capacity. If an individual needs to move into a longer term care home setting, they will be supplied with two suitable available options, supported via the work of the Care Sourcing team.
Information on Somerset’s various Intermediate Care Beds to support short term nursing needs and intervention (reablement), community hospitals, older people’s mental health and assessment only can be found in the Local Resources section.
Other relevant supporting information regarding intermediate care services is also in the ‘Local Resources’ section.
Community SPOC: The voluntary and community sector in Intermediate Care – Discharge/stepdown Home (Hub Option 5).
This service is a collaborative response from the British Red Cross (BRC) and the Community Council for Somerset (CCS) to both support acute discharge and pathway step-downs and divergence within Intermediate Care. The specification supports the provision for the two providers.
The current funding arrangements will be pooled into two separate financial agreements for each provider and the collaborative specification will allow for a flexible approach for Intermediate Care and to help develop greater opportunities to ensure that the Voluntary, Community & Social Enterprises (VCSE) can work to its full potential to support the wellbeing of our communities.
The service sets out a unified approach for the BRC and CCS and will cover the collaborative arrangements that will enable each provider to develop and grow its current skill base as well as acting as the front door triage point to the wider VCSE where local community arrangements can best meet need.
- To utilise community capacity and resilience to enable people to live well and stay as independent as possible in their own homes and communities.
- To provide a single point of reference to receive, allocate and track all referrals to provide a joined up triage, providing the best solution to support all discharge and divergence within the system wide intermediate care model in Somerset.
The service area will enable one reporting tool based on similar KPIS to be visible by the system to understand and articulate the demand, the solutions on offer and the outcomes of each solution against the current capacity.
The single point of access will be used by the following organisations:
- Somerset Foundation Trust: Musgrove Park Hospital, Community hospitals, Neighbourhood teams, District Nursing;
- Yeovil District Hospital;
- Royal United Hospital, Bath and Weston General Hospital;
- D2A, Rapid Response;
- Bedded Pathways 2 and 3;
- Primary Care.
The service area will enable one reporting tool to be visible by the system to articulate the demand and outcomes against the current capacity.
This service offers an opportunity for collaboration across health and social care in physical and mental health, communities and the voluntary sector. Through coproduction the group will ensure community and voluntary organisations are central to the Intermediate Care and divergence pathway by:
- Promoting independence for individuals within their own community;
- Working in partnership to embed the model across the countywide system;
- Highlighting gaps, opportunities through optimised resources and possible solutions for development;
- To enable targeted community development and support;
- To ensure there are community solutions to meet the needs of all individuals;
- Agree and champion the model across all organisations to manage expectations and build understanding;
- Make connections, sharing successes and learning.
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Operating Hours |
09:00hrs to 16:00hrs Monday to Friday. Monday to Friday for referrals. Service provision will vary according to service required. |
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Staff Professions involved |
Service Managers BRC Service Coordinators Community Agents BRC Support Workers Administration staff Volunteers |
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Acceptance criteria NB. Criteria is in place. Noted on page 49 of the contract. |
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Last Updated: December 16, 2022
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