Ready for discharge?
Last edited: March 24, 2025
Is this patient ready for discharge? Care staff, managers, and sometimes the patient themselves must ask this question endlessly. In this blog post, I will argue that it is the wrong question and that we fail to provide the best care to our patients by asking the wrong question without thought. Moreover, we fail to organise a more effective and efficient transfer of care. So, what is the correct question?
The right question is, “Is the next place ready to receive the patient?” Readiness is judged by asking five questions of the proposed setting:
- Is it available? This refers to being funded and having the capacity.
- Will it preserve the patient’s safety and well-being?
- Can it meet the patient’s disease-related diagnostic and treatment needs?
- Can it meet their rehabilitation needs?
- Will it satisfy the patient’s social needs?
The person can be transferred when the answer to all five questions is yes. The place, not the patient, must be ready.
Table of Contents
Introduction
On 26 January 2024, the UK government published statutory guidance on hospital discharge and community support. Although the principles sound eminently reasonable, this lengthy document is overly legalistic, prone to unwarranted statements claiming evidential support for suggestions, and seemingly unaware of the massive shortage of community resources. It aims to justify a very hard approach to removing people from hospitals. The guidance includes many references and links to other published official documents, most of which are written about a world where resources are available, not our world.
Annex D of the document covers “criteria to reside—maintaining good decision-making in acute settings.” Hospital inpatients who meet these criteria can remain; if not, they are considered ready for discharge. The authors recognise that some patients may need care or rehabilitation that will take time to arrange and have designated a process for transferring them elsewhere for further assessment.
Annex A of the document sets out the “discharge to assess—operational process.” Unfortunately, it does not specify that the place must have the knowledge and skills to undertake further assessment. The British Society of Physical and Rehabilitation Medicine’s BSPRM Rehabilitation and Complex Disability Management in Specialist Nursing Homes and Other Residential Units—Guidance to Best Practice gives standards for such a place.
The challenge of ‘delayed discharge’ is worldwide. For instance, a recent multicentre study in the United States found that 35% of patients in medical beds were ‘medically ready for discharge’, of which 28% had ‘major barriers’ to discharge and had been delayed for over seven days.
Ready for discharge – an analysis
A hospital admission happens within the implicit health service model, which is based on a biomedical model of health. Hospitals admit patients for the diagnosis and treatment of a disease. Modern hospitals run like a production line. Once medical actions are complete, the patient should leave the hospital because the human and other resources are no longer necessary.
This approach fails to consider a patient as a person. There is more to a patient than their disease. The person may be left unconscious through secondary damage to the brain or irreversible damage to the brain. They may have other conditions needing diagnosis and treatment that do not require a hospital stay but need attention. They may need ongoing disease monitoring or care to remain safe, a house to return to, or a care package to look after them. Currently, most hospitals do not manage the myriad of other problems. Hospitals consider different services responsible for any residual medical, social, and care needs a patient has. (see here)
Therefore, instead of taking responsibility for the whole patient, hospitals state that the patient is “ready for discharge”. They mean, “This patient no longer needs our expensive human and capital resource because we have done what is needed to diagnose and control their disease. He should leave.“
I suggest an alternative logic and phraseology might be more appropriate, “This patient would receive better and more appropriate care in [another setting].” This approach requires the hospital to:
- identify the patient’s needs
- find a setting able to meet their patient needs,
- make a referral,
- organise funding if needed,
- arrange the transfer once a suitable placement is found and the patient is ready to be taken.
Only then is the patient genuinely prepared for discharge.
When one rephrases the problem in this way, it becomes apparent what the real issues are.
The problem is not with discharge but with a transfer of responsibility for meeting the patient’s needs. This change in requirements arises because the original need for diagnosis and management of the disease has been sufficiently reduced, so the hospital no longer has a crucial role.
Other conditions become priorities, the patient’s needs change, and the hospital cannot satisfy the changed needs as well as another setting could. The transfer might be to another service within the same healthcare building or organisation. More commonly, it requires moving to a different service in another organisation in a different location.
The problem is not with the patient. All patients will eventually transfer out of the hospital. The service responsible for a patient should consider and plan for an eventual transfer and, once the patient no longer needs to be within their service, to arrange the transfer. Many patients will need further support after leaving.
Thus, the service responsible for a patient, including the acute hospital when a person is first admitted, must:
- identify the patient’s needs to be satisfied at the time of transfer
- discover a service or organisation (or a combination of services and organisations) that can meet those needs
- contact and liaise with the available services to check on availability, capability, and funding and then to organise a safe transfer of responsibility
- undertake a safe transfer
In many cases, the original service will also continue to monitor the disease and/or treatments.
Recognising that discharge is a transfer of care rather than the end of a patient’s need for care reveals that other parties are involved. The delay problem does not just concern the patient and the service caring for the patient. Instead, the difficulties arising in transferring patients out of an acute hospital are a societal concern. They emerge in the context of healthcare and social service systems but extend further into policies concerning housing and financial support and even to most social systems.
Society, represented by politicians, must take responsibility for the problem. A notorious case of a child who the hospital could not transfer from inappropriate hospital placement (here) illustrated that a discharge process does not occur in a vacuum and involves political choices.
To summarise, the patient is not the cause of a delayed discharge. The delays arise from difficulties in:
- the process of transferring care from one place and service to another and/or
- the provision within society of a sufficient number and variety of services and placements to meet the needs of patients.
Politicians are responsible for the problem of delayed discharges as they determine the available resources. Long delays in transferring care reflects politicians’ failure to take their commitment to the public seriously.
Delayed discharges – consequences.
The consequences of delays in the care transfer spread like ripples from the patient across the whole health and social care system and on to the family and other patients. A systematic review of papers describing the consequences of delayed discharges concluded that harms arise throughout the healthcare system. (here)
Starting with the patient, the documented consequences of delayed discharge include many adverse health consequences, such as:
- reduced levels of independence in activities,
- increased risk of death both during the delay and over the next year,
- many specific complications, including hospital-acquired infections,
- depression and anxiety, and
- a general loss of quality of life.
The service responsible for the patient also suffers. Staff often feel pressured to discharge people sooner than they wish, and they feel blamed for or guilty about the delay. Stress levels may increase, and morale may drop, especially if staff feel that they must neglect the patient’s needs to achieve a transfer of care. Interprofessional relationships within hospital teams suffer.
The hospital suffers. Often, hospitals are penalised for allowing or, more accurately, experiencing delays in transfer to another care provider or home. This punishment of the hospital leads to stress on the relationship between the hospital and other organisations, a relationship that needs to be good to achieve good patient care.
In the UK, the connection between Social Workers and social services is often weak, secondary to the joint problem of patients waiting in the hospital. Government policies and the contractual obligations imposed by commissioners exacerbate these consequences; the policies and contractual penalties do not help because they blame and punish the hospital when the system is to blame.
Last, the community suffers, especially other patients. Hospitals work to their capacity. The UK has one of the lowest numbers of beds in developed countries, and, as has been evident in the last two years, a sustained lack of adequate funding has left no capacity to manage any stress on the system. Delayed discharges stress the system, and other patients needing hospital care, both acute and elective, either fail to receive it or only do so after a delay.
To summarise, delaying a person’s discharge, better considered a delayed transfer of care to a different setting and care provider, harms all parties. It is particularly harmful in the UK, where health care and social care have been systematically under-resourced for the last 15-20 years. The system does not allow for adaptation and flexibility.
Transfers of care.
I will discuss a few studies investigating the transfer (discharge) process. A systematic review of qualitative studies examined the experiences of elderly patients who had been discharged home (here). The goal was to identify their experiences of adapting to living back at home after hospital admission.
The study identified four overarching themes:
- The patient experienced an insecure and unsafe transition. This theme included poor communication internally between hospital healthcare professionals, and externally between the healthcare team and the patient. Third, poor performance of essential parts of the process was attributed to a failure or absence of discharge policies.
- Once home, the patient experienced difficulties adapting to a new situation. These included many items related to confidence and preparation for the transfer, items concerning lack of social contact and a loss of purpose in life, and a general item related to a loss of independence and the new need for care.
- The patient’s dependence upon informal care. This mainly concerned a realisation that the transfer only succeeded because family and friends gave vital support across all spheres. Some patients felt guilty about this.
- The patient experienced a paternalistic approach from the healthcare team. The main aspects were the attitudes of healthcare staff and the professionals’ failure to listen to the patient.
Dirk Ubbink and colleagues undertook a mixed-methods study in a tertiary care hospital. They investigated the hospital’s discharge criteria as perceived by doctors, nurses, and patients. The wards studied covered different services, including paediatric services.
The focus groups involving healthcare professionals identified a host of criteria which the authors subsumed into four categories, three of which related to the patient and the last concerning organisational matters:
- Patient-related factors:
- a return to an acceptable or safe level of normality, physiological and functionally,
- not having any further tests needed or equipment to be used,
- not needing active monitoring of any specific condition
- Organisational:
- all arrangements needed for discharge, such as prescribing and supplying medication and arranging follow-up appointments.
In contrast to the extensive range of individual items given by professionals when asked, a review of the written criteria used in different services revealed another picture. Five of the top eleven criteria concerned non-medical criteria, which did not depend upon the patient’s clinical state. Most services set out ‘red flags’ standards, indicating that the service should not discharge a patient. Nevertheless, on review of the notes, services released 53 (12%) of 426 patients despite a red flag.
Strangely, the clinicians seemed to pay little attention to ongoing care needs. This may reflect the nature of a tertiary care hospital or a better-resourced care system in the Netherlands, with little difficulty meeting social care needs.
Verhaegh et al. (2019) studied 23 patients whose initial discharge was unsuccessful in another study set within the Dutch health and social care system. The 23 patients returned to the hospital within 30 days of discharge. Their qualitative investigation explored the initial release. They identified four relevant themes concerning the discharge process within the patients’ reports:
- Deficiencies in decision-making support, with two sub-themes
- Not knowing who the decision-maker is
- Not being involved in making the decision
- Aspects of patient education about discharge, also with two subthemes
- Receiving and understanding self-management instructions
- Importance of monitoring medication changes
- Unexpected difficulties in coping with the challenges of recovery after discharge
- Expectations about recovery; realisation that would not necessarily recover
- Modification of activities and social roles and activities
- Feelings about being dependent upon others
- Feeling of being a burden to informal caregivers
Waring et al. (2016) undertook the third detailed qualitative study of the discharge process. They studied the discharge of people admitted after stroke or hip fracture in two different settings: a small district hospital and a large three-hospital NHS organisation. They interviewed a wide range of professionals from various organisations, as well as patients and family carers.
The study focused on risks associated with the discharge process, the suggested immediate causes, and the suggested distal, systemic causes. It was interested in the reported perceptions but did not investigate any incidents.
The safety risks associated with discharge fell into four groups:
- Falls were the most concerning risk, including falls in the hospital, falls while going home, and falls at home.
- Medicines, their provision, instructions, education and use, were a second area of concern.
- Infection, both being discharged with active infection and acquiring an infection after discharge, was a third area of concern.
- Relapse, which refers to the patient being readmitted to the hospital. This harmful outcome was considered to arise from an inadequate provision of care.
The people interviewed for this study identified five areas of immediate causation:
- Inadequate assessment of a person’s readiness for discharge. This took many forms, including
- doctors not taking sufficient notice of information given by others, family and professionals,
- doctors only focusing on the primary disease, paying limited or no attention to other diseases present, and
- the discharging team overlooked or ignored other problems which may have been present at admission but caused risk at the time of discharge, such as being vulnerable or having cognitive losses.
- failure to finish diagnostic testing.
- failure to organise and provide medication appropriately, which had many systemic causes
- failure to organise and provide appropriate equipment at home, again arising from bureaucracy and a system failure
- failure to provide adequate and proper care and ongoing monitoring after discharge
The interviewees thought that system-level problems caused these failures. The data showed that arranging a discharge is a highly complex process involving many different people, organisations, financial systems, professions and agencies. Each has its own culture, resources, and rules that are different from those of other agencies or services. All parties have inadequate resources, so the whole process is under pressure. The authors identified five general domains, though they overlap:
- Planning of discharge and care, with no standard approach across wards, professions, services or agencies.
- Organising discharge, with great difficulties in communicating between services, especially across the hospital-community boundary with different funding rules, procedures and systems
- Scheduling the discharge and scheduling meetings between hospital and community teams.
- Resources available differ, and there are different rules for accessing resources and different priorities in providing them.
- Cultural and managerial differences, with a major political and management pressure on hospitals to discharge.
Transfers - discussion.
Most readers will not be surprised by these empirical study findings. The discharge process is complex and challenging because it involves many people working in different organisations, each with other methods and priorities. Different system parts have different funding mechanisms and organisational cultures and rarely share information. Only healthcare has good knowledge about the disease. Expert rehabilitation multiprofessional teams that include medical staff with rehabilitation expertise are not usually involved, so further difficulty arises from inaccurate formulation and prognosis and a failure to appreciate what rehabilitation could achieve.
Complex problems require a multidisciplinary team that includes people from all relevant organisations. In practice, hospitals often delegate responsibility to a discharge coordinator whose role is mainly the organisation of a process; they lack the broad range of knowledge required to organise an appropriate and safe discharge.
The problem arises within an extensive system, and the solution must involve all system parts. We will only solve it using a single team responsible for a patient’s transfer, working across all boundaries. In other words, it is not sufficient for senior managers in each organisation to agree that organisations should collaborate. Success depends upon the team working with a patient within a single framework, not working as a series of bridges between different organisations that still have various rules and policies.
These studies also show that the difficulties of transferring care are similar in many situations. Teams responsible for and policies for transferring care should be generic, with similar principles and procedures. While there will be some differences depending on factors such as age, type of hospital, and type of condition, the similarities are more significant than the differences.
The overwhelmingly powerful message is that all attempts to resolve this problem by assigning all responsibility to a single party from the many involved, usually the acute hospital, are doomed to fail—as is evident from experience over the last 20-30 years. Moreover, any system of incentives or punishments for perceived failures will reduce cooperation and collaboration between the parties involved.
Second, as news stories show, a failure to take a holistic view of the transfer process and the lack of sufficient resources in all parts of the health and social care system will increase acute hospital problems, especially urgent readmissions.
The qualitative studies highlight many vital matters. Services and organisations store documents in various incompatible ways. They use multiple measures to assess the same phenomenon, such as the ability to perform self-care activities. Each service and organisation has its own culture, which is often very different. The models of illness used to analyse and understand disease and a patient’s problems vary considerably among various services. The priorities of the organisation usually differ from those of other organisations. Funding rules vary significantly.
In summary, each organisation has characteristics that are often not compatible with features of other organisations that are also involved with the patient. This difference in characteristics arises within large organisations, for example, between a rehabilitation service and an acute admission service within a single hospital and between organisations such as community health services and local Social Services. The real triumph is that the process works in the face of these barriers.
Ready for discharge – the way forward.
Social care needs sufficient resources to meet the reasonable care needs of our population. Patients cannot leave hospitals at an appropriate time without an adequate quantity and variety of social care resources, including care homes. Politicians have overlooked this undeniable fact, believing technology, privatisation, reorganised management, and exhortation will resolve the problem. This belief ignores the fact that most patients depend upon state funding, which has been reduced.
Assuming sufficient resources are available (an unlikely assumption, I fear), the different parties must discuss working within a common framework. The best one is the biopsychosocial model of illness, as it encompasses various parties’ differing interests. Next, they must agree on a format or template for referrals from one part to another. Given the vast range of patients, services, and settings, this must be a high-level outline. Third, there needs to be a discussion on the best way to share important information as responsibility transfers from service to service.
As a first step, the rehabilitation services within an area could collaborate in a single rehabilitation network. This change would demonstrate that separate services can work together. Learning disability services already use a shared model that covers health, social care, and vocational activities. It is not an impossible dream.
Conclusion
Everyone says they want collaborative, person-centred services across all agencies to provide seamless care. However, politicians, policymakers, and management organisations have enforced a system centred on finances and services, with rewards for competition and disincentives for collaboration. To add insult to injury, the whole system is under-resourced, and based on a medical model rather than a holistic biopsychosocial model of illness.
A seamless service within a single organisation covering health, social care, and other agencies would be too extensive to manage. It would likely develop its separate service and budgetary silos. The alternative and best solution is to organise formal and comprehensive rehabilitation networks, which must include nursing homes, which have a vital role to play. The funding agencies should encourage collaboration and flexible or joint working between services.
