Hospitals should consider actions outlined in High Impact Areas A, B and C to maximise and maintain a person’s independence throughout their hospital stay, enabling optimised prescription of care at discharge.
E1. Embed Optimal Handed Care consistently across all discharge pathways to ensure a consistent approach
It feels like every time he goes into the hospital; he comes back with a bit more deconditioning i.e. his ability deteriorates so he has to have two carers and then overtime his strength builds back up and then you can move to one carer."
This can be achieved by:
- Integrated discharge pathways with optimal handed care: Embed optimal handed care in each step of the discharge pathways, where system partners work seamlessly together to support the person on their journey out of hospital and into community in line with person-centred principles. This will require:
- consistent application of risk assessments for optimal handed care across all care settings, enabled through system-wide education and training, such as integrated discharge teams, intermediate care services, reablement services and any voluntary sector organisations (if appropriate) part of discharge pathway, fully trained in optimal
- moving and handling techniques and equipment
- an increased and prompt provision of consistent moving and handling equipment across all care settings. For example, where possible, same equipment across hospitals and community.
- a consistent system-wide training provision to deliver OHC across all partners focused on thinking about the person first. For example, does a person really needs 4 x double handed care visits per day at discharge? Could the tasks involved in second and third visit be safely delivered with one person.
- Discharge to Assess: It is crucial that the hospitals aim to follow a true discharge to assess process, whereby the moving and handling needs at discharge are assessed with a clear understanding and assurance of a comprehensive risk assessment in the community within 24-72 hours.
- Enhancing social support: Identify and address gaps in the person’s social support networks as part of early assessment and personalised care planning, to enable optimal handed care. Maximise the use of existing channels such as social prescribing and connect people with volunteer organisations that provide companionship, transportation, or assistance with household tasks. Provide information, and where appropriate, support and training for optimal handed care to family members who are willing to provide care for the person.
- Transfer of care into community: Ensure a seamless transition of care from acute into the community and consistent application of optimal handed care approach through the risk assessment framework.
The above actions should be considered in conjunction with Statutory guidance for Hospital discharge and Community Support.
E2. Ensure clear and consistent communication at the point of discharge to manage expectations for both staff and people receiving care.
This can be achieved by:
- Use of right language: The language used by health and social care professionals strongly influences how people, carers, and providers perceive ongoing care needs. Professionals should instead use proportionate, enabling language that focuses on individual goals and recovery potential. For example, discharge discussions should frame care as “a support package that meets your needs appropriately and will be reviewed and adapted as you recover.” This approach communicates flexibility, encourages active participation in rehabilitation, and aligns expectations across the multidisciplinary team, people, and carers.
- Embed the cultural and linguistic shift across hospitals and community by:
- incorporating communication and expectation-management training into
- discharge planning for all staff
- audit discharge documentation and care summaries to ensure language
- reflects OHC principles
- embed this expectation within system-wide discharge policies and
- communication frameworks
- use case examples and reflective supervision to model positive, enabling language in practice.