Date published: 7 July, 2026
Date last updated: 7 July, 2026
Elective care, Urgent and emergency care

Model discharge pathway

Introduction

Why timely discharge matters

Safe, timely discharge from an acute or community hospital bed is a critical part of patient care and onward recovery. Planned proactively and delivered well, timely discharge can restore independence, improve outcomes and release capacity for those most in need of acute and community bedded care.

Staying in hospital longer than clinically necessary carries well-evidenced risks, including deconditioning, hospital-acquired infection, delirium, falls and greater dependence on long-term social care. These risks increase with every extra day in hospital.

Unnecessarily prolonged stays also place significant pressure on urgent and emergency care capacity, contributing to ambulance handover delays, corridor care and reduced capacity for elective care.

Timely, clinically-led discharge – supported by effective operational support – is therefore central to patient safety and flow.

Purpose and scope

While the components of good discharge are well understood, they are not applied consistently. There is still unwarranted variation between wards, sites and systems, and across different days and times of year.

Delivering timely, high-quality discharge consistently requires a shift in mindset: only admitting patients who need inpatient care, and supporting them to leave hospital as soon as it is no longer required. This means treating discharge as a core part of patient care from the point of admission, rather than as an activity that begins when a patient is ready to leave hospital.

This publication sets out the model needed to make timely, clinically-led discharge routine – so all patients receive the right care, at the right time, no matter when or where they are treated.  

The model applies to hospital and community bedded care and addresses:

  • in‑hospital discharge planning and delivery
  • daily ward-based practices within the control of hospital teams
  • standardising basic processes to reduce variation

It applies to patients of all ages across both physical and mental health. Separate guidance covers mental health inpatient discharge, but this publication recognises the need for joined-up approaches where physical and mental health needs overlap.

This publication is designed to support clinical and operational leaders across acute and community hospital trusts. It is also relevant to regional and integrated care board (ICB) discharge, flow and urgent and emergency care (UEC) leads, as well as wider system partners involved in supporting discharge pathways.

Appendix 2 includes further detail on supporting cohorts most at risk of harm from delayed discharge.

Working with system partners

This publication does not set new requirements for social care providers. However, safe discharge for pathways 1 to 3 depends on the timely involvement of local authorities, social care, housing and voluntary, community, faith and social enterprise (VCFSE) partners.

Shared ways of working between organisations, and a common understanding of data, are essential to ensure the required discharge capacity is in place across the system.

Further detail on complex discharges and system co-ordination is set out in existing national and statutory guidance and will continue to be developed jointly with health and local government partners (see appendix 3).

A whole pathway approach

Effective discharge also depends on what happens earlier in the hospital stay. Early senior clinical decision-making in the first 72 hours, clear treatment and discharge intent (communicated with patients and carers), and adherence to admission criteria all play a critical role in enabling discharge later in the pathway.

Only patients who require hospital bedded care should be admitted, with early decisions made about those who can be supported through alternative pathways such as same day emergency care (SDEC) and Hospital at Home (also known as virtual wards).

As neighbourhood-based care develops, local teams will play a critical role in supporting patients with complex needs, including frailty and end-of-life care needs. This will help avoid unnecessary hospital admissions and support timely discharge when admission is needed.

Over time, this will include proactive in‑reach into wards, with neighbourhood and hospital teams working together to co-ordinate an early discharge home with appropriate support, or to an alternative setting, where necessary. These actions support not only timely discharge but also continuity of care and prevention of avoidable readmission, particularly for patients at risk of recurrent long stays.

Systems should ensure discharge processes are integrated with existing guidance, including:

See appendix 3 for further related guidance.

7 principles of discharge

1. Discharge is a clinical decision, not an administrative one

It is planned from the point of admission and enabled by efficient, consistent operational processes that are everyone’s responsibility.

2. Staying in hospital longer than necessary causes harm

Prolonged hospital stays increase the risk of deconditioning, infection, delirium and sometimes result in a life-changing loss of independence for older adults. Keeping someone in a hospital bed when they no longer need it is a safety risk. For children and young people, time away from school and home can also have significant negative effects.

3. Timely discharge is essential for patient flow and safety across the urgent and emergency pathway

The whole urgent and emergency care pathway depends on patients leaving hospital when they are ready. Maintaining a daily oversight of discharge flow, aligned to admission demand, reduces the risk of prolonged waits for admission in emergency departments and corridor care.

4. Discharge home or to the usual place of residence is the default

Discharge home (pathway 0) or home with short-term support (pathway 1) should be the norm where safe. Bed-based pathways (pathways 2 and 3) are used only when needed.

5. Discharge is everyone’s business, every day – with empowerment and clear decision rights

Multidisciplinary working is essential, with clear roles and accountability so everyone can act confidently within their role to support discharge.

6. Patients and carers (including parents of children and young people) are partners in achieving high-quality discharge

Discharge planning must involve patients and carers early and meaningfully, in line with statutory duties (Health and Care Act 2022 s.91).

7. Decisions are informed by timely, high-quality data and transparency

Consistent metrics should be visible to frontline teams and system leaders to support action and learning. Clear definitions and everyday language must be used, so staff, patients and partners all understand the next steps.

The patient’s and carer’s perspective

Patient and carer feedback, alongside published evidence, consistently shows that early, meaningful involvement in discharge planning is essential.

This is not optional. NHS trusts have a statutory duty to involve patients and their carers (including parents of children and young people) as early as possible when post‑discharge care and support is likely to be needed.

Family members and carers should be asked about their ability and willingness to provide support, and where caring responsibilities are new or have changed, they should be offered referral for a statutory carer’s assessment.

What patients and their carers want discharge to be

Informed

They understand the plan, medications, follow-up and next steps. They know what to do if their condition worsens and where to go for support.

Involved

They genuinely participate in planning and are involved as decisions are made – not told afterwards.

Supported

Care is arranged and ready – not left for them to sort out.

Timely and safe

Not rushed out too early, and not left waiting too long.

Respectful

They feel listened to and treated as individuals, not as tasks to complete.

Personalised

Their individual circumstances are considered in discharge planning, such as their home environment and availability of family or carers.

Core elements for discharge from acute hospitals

In most hospitals, for the majority of patients, timely discharge is within the control of clinical teams. Effective flow therefore depends on reliable delivery of high-volume routine discharge activity alongside management of more complex pathways.

This section sets out the core elements and practices for planning, co-ordinating and delivering safe, timely discharge for every inpatient stay across acute settings. They apply to all discharges, regardless of complexity or destination.

Although they follow a similar overall approach, the specific elements and how they are delivered may differ in community bedded settings. The specific practices for community bedded settings are therefore described in the next section.

Discharge planning from admission

In elective care, discharge planning begins at the preoperative assessment stage to reduce the risk of delayed discharge, particularly over weekends.

In non-elective care, discharge planning starts at admission, with clarity on why the patient is being admitted, why care can’t be provided out of hospital, what treatment or investigation is required, and how long this is expected to take.

All admitted patients are reviewed by an expert clinical decision‑maker (normally a consultant) within 6 hours during the day and 14 hours overnight to confirm the clinical plan and discharge intent.

An integrated management plan with expected date of discharge and patient-specific physiological and functional discharge criteria is in place, along with completed medicines reconciliation within 24 hours. 

The intended discharge pathway and destination (including Hospital at Home where appropriate) are identified early and remain visible to the ward team.

From admission, reviews focus on optimising the patient’s condition and preventing hospital-acquired deconditioning. This includes recording the patient’s baseline functional abilities so goals can be set for returning to that level and beginning therapies and mobilisation.

The clinical plan and discharge destination are discussed early with the patient and, where appropriate, their family or carers. Advocacy and support are available for patients who lack capacity and/or have no informal carers.

Choice is supported through early, personalised conversations. However, people do not have a right to remain in hospital once they no longer require inpatient care while waiting for a preferred option to become available. Interim care placements are considered when placements of choice cannot be delivered within appropriate timescales.

Daily focus on discharge and flow

Daily structured consultant-led board rounds and ward rounds, supported by the multidisciplinary team, take place 7 days a week. They:

  • review progress towards discharge and adapt plans if needed
  • confirm discharge readiness (including expected day of discharge, destination and barriers)
  • identify and escalate actions needed to progress care

This ensures that patients in hospital are being actively managed each day, and are not waiting for diagnostics or assessments.

All patients are visible in a daily ward-level process that maintains oversight of progress towards discharge. While the depth of discussion may vary, every patient has a clear, up-to-date plan and actions to progress their care.

Weekend arrangements maintain daily reviews, while adapting processes as appropriate, to prioritise decision‑making, continuity of discharge activity and safe system flow.

For every patient, the ward team is able to answer 3 simple questions:

  • does this patient still require care that can only be delivered in an inpatient setting?
  • if not, what pathway are they being discharged on?
  • what is preventing discharge today?

The ward team considers whether any remaining activities normally carried out in hospital could be carried out in another setting, for example, via Hospital at Home, as an outpatient or through a planned return using a ‘ticket home’ approach, rather than extending the inpatient stay.

Patients are clearly differentiated between those leaving today, those expected to leave in the next 24 to 48 hours, and those who still require inpatient care, with clarity on next steps to progress towards a timely discharge.

Hospitals predict and actively manage bed demand and capacity on a day‑to‑day basis, with a consistent number of discharges planned each day to assist timely onward capacity and flow. Data is proactively shared with partners to support planning across the system.

Preparing in advance for the day of discharge

Medical, nursing, therapy, pharmacy, discharge co-ordination, social care, community and system partners (such as local authorities and housing) complete tasks in parallel, not sequentially.

Community in-reach supports early, co-ordinated discharge planning, with community nurses or therapists attending the acute ward to assess post-discharge needs while patients are still receiving treatment.

Steps are taken early to avoid delays on the day of discharge. For example, pharmacy (TTOs), therapy, equipment, documentation and transport requirements are identified early and tracked to avoid delay. Known dependencies (for example, tests) are planned in advance rather than identified on the day.

Digital solutions, including automation and artificial intelligence-enabled tools, where clinically appropriate and governed appropriately, can support the timely preparation of discharge documentation and reduce administrative burden on frontline teams.

Criteria‑led discharge

Criteria-led discharge is the default approach to discharge planning for all teams.

There is a clear and consistent understanding of when a patient is ready for discharge. This is the point at which the patient no longer requires care that can only be provided in a hospital setting and is better supported at home or in the community.

Nationally defined criteria to reside support this decision alongside clinical judgement on where the patient’s needs are best met, and the balance of risk of avoidable harm.

Criteria to reside are translated locally into clear, ward-friendly language that reflects current models of care, including care that can safely be provided at home or in the community. Patients who are ready for discharge (that is, have no criteria to reside) are assigned to a relevant discharge pathway (pathways 0 to 3), with staff understanding the pathways and the actions required.

Patient‑specific discharge criteria are agreed in advance by an expert clinical decision‑maker and understood by the multidisciplinary team. Nursing and allied health professional (AHP) staff are empowered and supported to discharge patients once patient-specific criteria have been met, without waiting for further medical sign‑off or ward round.

Supported by agreed protocols, criteria-led discharge approaches enable out‑of‑hours and weekend medical staff, including on‑call consultants and resident doctors, to make prompt and safe discharge decisions and reduce avoidable weekend stays.

Early-in-day discharge

Early‑in‑day discharge is the norm, particularly for patients on criteria‑led pathways.

7‑day enabling services (including pharmacy, therapies, diagnostics and transport) support discharge preparation and early-in‑day discharge.

If a patient is otherwise ready for discharge, non‑urgent tests, investigations or consultations are completed after discharge, either as an outpatient or via a planned return using a ‘ticket home’ approach.

Discharge lounge

Discharge lounges can support early-in-day discharge and release inpatient bed capacity. They must be able to accept non-ambulant patients awaiting discharge, including those who are bed-bound.

Discharge lounges operate a ‘pull’ model, actively identifying patients who are ready for discharge across wards, and have clear acceptance criteria.

They have extended opening hours (at least 12 hours a day) to support discharge ambitions across 7 days, and a non-bedded policy is in place to preserve capacity and avoid overnight stays.

Discharge from the discharge lounge happens as soon as it is possible and safe – often within 2 hours or on the same day (preferably before 5pm).

Where discharge can be completed efficiently from the ward, this is an accepted alternative to using a discharge lounge.

Home first approach

Where possible, patients are discharged as default to their home or normal place of residence. Agreed processes are in place across system partners to support safe transfers of care.

Ward staff understand the role of Hospital at Home, intermediate care and community services in supporting patients’ ongoing medical and therapy needs to expedite discharge from hospital care.

Eligibility criteria and referral routes to those services are simple, clear and used early, aligned to the expected day of discharge, enabling planned transfers with clear clinical responsibility and handover. Capacity across services can be seen by discharge teams.

In-hospital assessments focus on identifying the discharge pathway, immediate support needed for safe discharge and next steps. Most assessments for longer-term care and support take place after discharge, ideally in the person’s usual place of residence (for example, in line with discharge-to-assess and ‘home first’ principles).

Post-discharge follow-up may be used, particularly for older people with frailty. This can include a simple telephone call by hospital or neighbourhood teams within 24 hours of discharge to support safe transition home and confirm that care arrangements are in place and medications are understood.

Active management of delays

Hospitals should maintain a simple pathway 0-3 view, showing whether the patient is waiting for simple home discharge, home with support, a community bed or interim placement or a new care home placement (see definitions in appendix 1).This should be agreed locally with system partners, including local authorities, so that pathway definitions, ownership and reasons for delay are understood consistently.

When a patient is not discharged as expected, the specific reason for delay is clearly identified. Information on delays is used to prompt immediate action by a multidisciplinary team across health, social care, and housing. Each delay is consistently recorded, has a named owner, and clear actions with agreed timescales. Case management tools (for example, Optica-type systems) support real-time tracking and co-ordination across organisations.

Senior clinical and operational forums review aggregated delay data and delay reasons to identify risks, target improvement activities and pinpoint avoidable in-hospital process delays. This includes delays relating to diagnostics, specialty review, medicines, therapy, transport and documentation.

System co-ordination

A single point of co-ordination across acute, community and social care partners, such as care transfer hubs, works with wards to progress complex discharges that cannot be completed by the hospital alone.

There is real-time visibility of community capacity (for example, available community beds) to facilitate flow.

Where discharge relies on services outside the hospital, timely discharge depends on pre‑agreed, commissioned arrangements with system partners, including community, voluntary and specialist providers, with clear capacity, responsibilities and escalation routes.

Discharge co-ordination resources are aligned with the areas of highest discharge activity, including high-volume areas, such as acute medicine, and are available 7 days a week.

Surge and contingency plans are in place with system partners (including funding arrangements) to manage periods when demand exceeds planned provision, particularly during busier winter periods.

Leadership, oversight and escalation

A named clinician is responsible for ensuring timely discharge for each patient and works with a cross-organisational multidisciplinary team to co-ordinate more complex discharges (for example, a care transfer hub or equivalent).

Each multidisciplinary team member’s role and decision rights in expediting discharge are clear. For example, a senior nurse can initiate a social care referral, with ward managers (or equivalent), maintaining responsibility for progressing the patient’s discharge until they leave hospital.

Issues that cannot be resolved at ward or care-transfer-hub level are escalated early and acted on.

Having an integrated single senior co-ordinator, working across acute, community and local authority partners, can help resolve cross-organisational barriers to timely discharge.

Senior clinical and operational leaders provide visible oversight, actively supporting daily flow and unblocking delays, including those arising at system interfaces.

Data supports action

Hospitals share a single, consistent view of core discharge information, including expected dates of discharge, patients who are ready for discharge (that is, have no criteria to reside) and the patient’s discharge pathway (0-3).

Discharge ready date (DRD), discharge pathway definitions and reasons for delay are consistently recorded in electronic patient records (EPRs) and understood by ward staff and local partners. Responsibilities for recording data are assigned and clearly understood by teams. The data is used to drive operational decision‑making as well as board-level assurance.

Core discharge information is accompanied by data that appropriately links discharge to flow throughout the hospital. This includes comparing the number of patients whose discharge is delayed, or who are clinically appropriate for discharge (for example, with low and stable National Early Warning Score (NEWS) and/or awaiting observations and/or diagnostics that could be delivered through Hospital at Home or as an outpatient), with the number of patients waiting more than 12 hours in emergency departments for admission and/or receiving care in corridors.

Core elements for discharge from community hospitals

Patients should experience the same quality of discharge, regardless of whether they are receiving care in an acute or community setting.

Around 40% of discharge delays in community bedded settings relate to in-house and transition processes, such as clinical oversight for discharge decisions and the timeframes involved in individual funding decisions. Early planning, clinical oversight, ongoing patient reviews and close working with system partners are therefore vital to help people return home as soon as they are ready.

The elements below set out the minimum practical requirements that community providers should have in place, and are aligned with the Community Bed Delivery Model (pending publication).

Discharge planning from admission

Every person in a community bed has a logged expected discharge date that is regularly reviewed by the multidisciplinary team.

Frequent ward and board rounds supported by a multidisciplinary team are embedded, with oversight from the accountable clinician to agree and expedite discharge dates and next steps, 7 days a week.

All staff understand and use a clear methodology for identifying people who no longer need to be in the service (that is, no criteria to reside).

Discharges are able to take place 7 days a week, supported by extended pharmacy hours and joint advance planning for medication needs.

Clinical oversight

Services are led by a clearly identified accountable clinician, on site where possible, supported by a multidisciplinary team, which enables clinical and therapy decisions to be made daily.

Where possible, clinical oversight models are linked or unified across home and bed-based services, making best use of capacity and embedding a ‘pull model’, which actively tracks and transfers people between services as they are ready for discharge.

Providers empower and support staff to implement policy and manage difficult conversations with patients and families, where necessary.

Home first approach

There is an ethos of ‘home first’ within the bedded care setting. Staff work with the patient towards the goal of returning home and ensure that people are as mobile and self-sufficient as possible whilst in the service, and do not stay in bedded care longer than necessary.

System co-ordination

Multidisciplinary team and system partners plan early and work together to streamline and reduce the administrative burden of discharge processes such as funding decisions, equipment ordering and liaison with, for example, housing authorities.

Where delays occur elsewhere in the system, such as with loan equipment, partners actively manage the risk, weighing the impact of the delay against the risks of keeping patients in hospital unnecessarily.

Data support actions

Data on capacity, patient flow, quality and discharge delays should form part of everyday management discussions with improvement key performance indicators (KPIs) designed with and visible to all staff.

What organisations need in place to deliver the model

Baselining, demand and capacity planning

Many components of this model discharge pathway are already in place. However, significant variation remains across organisations and across days and times of the week.

To understand their baseline, every hospital setting should compare their current operating model and practices against the core elements set out in this document to identify gaps and develop their own plans for improvement.

To maintain safe bed availability and patient flow, providers need a clear understanding of the discharge activity required to balance admissions. This means maintaining daily oversight of 3 interrelated factors: the number of discharges delivered, the timing of those discharges within the day, and the variability in discharge output across days and weeks.

Where discharge activity is insufficient in volume, occurs too late in the day, or varies significantly across days and times, risks increase for both patients waiting to leave hospital and those waiting to be admitted.

In addition, providers should seek to understand the number of patients who are clinically stable and no longer require inpatient care but remain in hospital awaiting further observation, review, diagnostics, assessment, discharge arrangements or community capacity. Local approaches may vary, but this cohort should be routinely reviewed to identify opportunities for earlier transfer of care through home first, Hospital at Home and community services.

Improvement plans should embed demand and capacity modelling across all discharge pathways, including for children and young people. Commissioning arrangements need to be in place across health and social care to ensure sufficient capacity for timely, safe discharge across all pathways. This requires ongoing conversations between partners about current and future capacity needs.

Systems will already be doing this through Better Care Fund (BCF) and wider commissioning arrangements, including through place‑based partnerships, recognising that some elements of discharge flow sit beyond the direct control of individual providers.

Leadership, roles and responsibilities

Each system partner should identify a named executive director with overall accountability for discharge performance.

This should be supported by clear operational and clinical leadership for discharge at division, specialty and ward level, with clear routes for escalation and resolution.

They should ensure discharge performance is regularly discussed at full board meetings. Senior trust executives (chief operating officers, chief medical officers and chief nursing officers) should also routinely lead hospital discharge meetings to support flow and unblock delays.

Culture change in discharge is sustained through clear accountability, visible senior leadership, and consistent escalation. It should be clear who is responsible for making discharge decisions, progressing actions and resolving delays at each stage of the patient’s journey.

Where responsibility is ambiguous, delay becomes normalised. Promoting a culture in which discharge planning is seen as a clinical intervention, not simply an administrative task, is essential.

Executive ward rounds, for example, targeting flow and delayed discharges can help resolve barriers and emphasise the importance of timely discharge for both individuals and the wider urgent and emergency care pathway.

Core metrics for improvement

Alongside this publication, a review of data requirements will be undertaken to simplify and consolidate the range of discharge measures and metrics into a coherent set of operational tools to support hospital and system flow.

In the immediate term, trusts should use 2 simple operational metrics, which can be used to improve performance, by linking what can be easily measured and understood at ward and site level through to the board.

At an individual setting level, these are:

  • the number of discharges required and delivered each day by pathway 0 to 3, visible at ward and site level, to support safe bed availability and flow
  • the number of patients who no longer require care in a hospital or community bedded setting and are better supported at home or in the community by pathway 0 to 3, that is, they do not meet criteria to reside and are ready for discharge

Trusts should ensure that ward staff and partners know their daily ward level performance against expectations across these 2 metrics as well as the average length of delay across each pathway at site level to ensure a shared understanding of demand and capacity, and reduce avoidable delay. Locally these metrics should be reported for children as well as adults and considered separately.

These 2 metrics will also be tracked nationally.

To support this, the acute discharge situation report (sitrep) will be refreshed to report delays for patients who no longer require care in a hospital bed, that is, do not meet the criteria to reside and are ready for discharge by pathway. This will operate as a time‑limited measure, pending development of a sustainable approach to delivering pathway flow data.

Greater transparency on delays by discharge pathway will make it easier to identify where performance can be improved within ward teams’ direct delivery, and where co-ordinated action across hospital, community services, housing and local authority partners is required to improve performance on pathways 1 to 3.

We will complete quarterly reviews to highlight the disproportionate impact of the very long complex delays and prioritise their resolution with all partners across health and social care.

Workforce

Implementing criteria‑led discharge and reliable early discharge decision‑making depends on having the right workforce capabilities and availability in place.

This includes appropriate job planning and rotas to support continuity of care, with time allocated for regular ward rounds and board rounds, and staff with the competencies, training and confidence to act on agreed discharge criteria and protocols.

There should be shared understanding across professions about roles (for example, when therapy input is required and when it is not), responsibilities and escalation.

Workforce arrangements should support delivery across 7 days, including access to senior clinical decision‑makers and continuity of medical, nursing and allied health professions input, as well as out-of-hours and weekend access to pharmacy and patient transport.

This enables agreed discharge plans to progress consistently and reduces avoidable delay when patients are ready to leave hospital.

Appendix 1: Pathway definitions

This appendix sets out different pathways of care, in line with existing national guidance.

Pathway 0: simple discharge home

Discharge home or to usual residence, with no new or additional health or social care needs.

What this includes

  • ward‑led discharge
  • no care transfer hub (or equivalent) involvement, unless necessary

Criteria

  • no new support required
  • meets criteria for discharge
  • discharge ready date (DRD) set to today

Pathway 1: home with support

Discharge home or to usual residence with new or additional health and/or social care and support arranged by the care transfer hub (or equivalent).

What this includes (as required)

  • home-based intermediate care (rehabilitation, reablement and recovery) services
  • end-of-life care at home
  • district nursing
  • long-term care at home (community bed discharges only)
  • hub‑co-ordinated support

Criteria

  • new or additional support needed at home

Pathway 2: community bed

Transfer to a bedded intermediate care setting where home is temporarily unsafe or intensive therapy is needed.

What this includes
  • bed-based intermediate care, including time-limited rehabilitation, reablement and recovery
  • typically time-limited (often up to around 6 weeks), depending on the local model

Criteria

  • requires short‑term bed‑based rehabilitation and recovery that cannot be provided at home
  • requires an interim placement while awaiting placement of choice

Pathway 3: new care home placement

Discharge to a new residential or nursing home setting, co-ordinated through the care transfer hub.

This pathway should only be used in exceptional circumstances, and with facilitation of patient choice, for people with the most complex needs who are considered likely to need long-term residential or nursing care.

For children and young people, this would typically be a new placement in a specialist residential setting.

What this includes

  • new residential or nursing home setting
  • consideration of Continuing Healthcare (CHC)
  • support for patient choice

Criteria

  • likely to require long‑term 24‑hour care

Important note

A return to a person’s usual care or nursing home may be pathway 0, where no new or additional support is required, or pathway 1, where time-limited short-term support is needed; local operational reporting should distinguish this from a new care home placement, which is pathway 3.

Appendix 2: Considerations for patients at greater risk from delayed discharge

Some patient groups are more likely to experience harm if discharge is delayed and require more proactive, tailored pathways.

Focused pathways should be in place for the following cohorts, supported by regular review of local data on length of stay, delay and outcomes for these groups.

The greatest risk is often seen when patients experience multiple overlapping vulnerabilities (for example frailty alongside cognitive impairment, housing insecurity or mental health needs). These situations require co-ordinated multidisciplinary and multi‑agency planning.

People living with frailty, dementia and/or delirium

Patients living with frailty and those living with dementia are at increased risk of deconditioning, delirium, falls and loss of independence from a prolonged hospital stay. Dementia and other forms of cognitive impairment can affect communication, decision-making and discharge planning. Patients with frailty, dementia or delirium should have pathways that support early identification, carer involvement, continuity of care and discharge to the most appropriate setting.

Delirium should be recognised as a common acute medical syndrome, which may affect people with frailty, dementia or both, requiring identification and treatment of underlying causes alongside discharge planning, while avoiding unnecessary delay once the person is medically stable.

Discharge planning should be based on an understanding of the person’s usual baseline (including cognition, mobility, function, communication, continence and social circumstances), with family and carers involved early as key care partners. Systems should embed the consistent use of recognised tools (for example Clinical Frailty Scale and 4AT) across admission, review, discharge planning and handover.

Neighbourhood-based services should play a central role in preventing unnecessary admission and enabling timely discharge, supporting co-ordinated, wraparound care to return people to their usual place of residence wherever safe.

Home first principles should be applied equitably, with reasonable adjustments for cognitive and behavioural needs and access to reablement and intermediate care. Decisions about long-term care should be avoided during acute illness where recovery remains possible, with clear handover of cognitive and functional risks to support safe transitions.

Systems should align with the NHS England frailty approach, the High Impact Change Model: Improving the timely and effective discharge of people with dementia and delirium into the community and statutory hospital discharge guidance.

People with palliative and end-of-life care needs

Patients with palliative care needs (physical, psychological, social, spiritual and cultural) associated with their condition, and those at the end of life, should not experience avoidable discharge delay, particularly where this conflicts with their advance care plan or preferred place of care. 

These needs may be identified before or during admission and should trigger co-ordinated discharge planning that reflects the person’s wishes, with appropriate information recorded and shared. 

Ward staff should identify patient need early, ensuring timely assessment of palliative care and end-of-life care needs, access to shared care records and specialist palliative care where required, with rapid co-ordination of medicines, equipment and community support to enable safe and timely discharge.

This approach includes prioritising rapid discharge for those approaching the last days or weeks of life. Clear, compassionate communication with the person and those important to them is essential, including providing information on what to expect and who to contact.

People experiencing homelessness or housing insecurity

Housing status should be identified at the earliest opportunity, and discharge planning should begin from admission for anyone experiencing homeless or housing insecurity or has no recourse to public funds.

Best practice is for the inclusion of dedicated housing options officers in the care transfer hub, with in-reach to wards for early discharge planning with the benefit of access to NHS and local authority systems.

Discharge must not take place without a safe and appropriate destination and should involve local authorities, housing services and relevant specialist support, reflecting existing statutory duties and national commitments on preventing and relieving homelessness.

Patients with no recourse to public funds (NRPF) must be identified early in admission, with discharge planning initiated promptly and involving relevant agencies to ensure a lawful, safe and co-ordinated plan for accommodation and support, recognising that standard housing pathways may not be available.

Systems should align with the published guidance Discharging people at risk of or experiencing homelessness and with wider NHS England inclusion health resources.

People with mental health needs, a learning disability and/or neurodivergence

Patients with mental health needs or neurodivergent profiles may face more complex discharge pathways, particularly where needs are not recognised early or reasonable adjustments are not made.

Discharge planning should consider the interactions between physical health, mental health and neurodiversity, with timely specialist input and co-ordination with community services where needed.

Separate guidance applies to discharge from mental health inpatient settings (see appendix 3), but this publication recognises the importance of joined-up approaches for people whose physical and mental health needs overlap.

For children and young people, systems should align with the principles set out in Supporting children and young people with mental health needs in acute paediatric settings: A framework for systems. This guidance promotes co-ordinated, whole system support before and after discharge.

Since 2023, nationally funded senior clinician Mental Health Champions have been established in acute paediatric settings to strengthen leadership for children’s mental health, improve integration between physical and mental health services, and support clear, safe and timely care and discharge pathways.

Babies, children and young people

Hospital admissions can be upsetting and disruptive for children and their families. Where possible, neighbourhood health teams should support children to receive care in the community and, when children do require admission, enable earlier discharge.

Children and young people cannot be discharged unless there is a safe, appropriate destination. Discharge planning should include explicit assessment of safeguarding risks, parental responsibility, advocacy needs and the child’s legal status, particularly for children and young people with special educational needs, disabilities, mental health needs, or unstable home circumstances.

Early consideration of continuing care requirements should form part of discharge planning, including timely engagement with relevant commissioners and partners to support decision-making and avoid delays to discharge.

Children and young people, and their parents and carers, should be treated as equal partners in discharge planning, with clear, honest communication about timescales, risks and system constraints, and active involvement in multidisciplinary discussions. Clear advice on follow-up arrangements and emergency contacts should be provided.

Discharge plans should account for the training, competence and confidence of parents/carers and community staff, with time built in for training, competency assessment and safe handover where complex care or equipment is required. This training is initiated as early as possible when the need is identified, rather than being left until close to the planned discharge date.

Discharge guidance and support

Urgent and emergency pathway guidance

Neighbourhood and community health services guidance

Frailty

Children and young people

Mental health and crisis care

Workforce, funding, safety and quality

Patient engagement and experience

Publication reference: PRN02543

Date published: 7 July, 2026
Date last updated: 7 July, 2026