Hospital transfer, discharge change and continuity of care

When a resident is transferred for assessment, clear, accurate information must travel with them. NICE guidance on transition between hospital and care settings specifies that transfers and discharges should include timely summaries, medicines information and plans for continuity of care. For care home staff, this means sending and receiving specific clinical and care details rather than vague notes such as "off legs" or "not well."

On return, any new medicines, changes to treatment or monitoring, swallowing advice, follow-up arrangements or ongoing risks must be identified and recorded in the live care plan. A resident may appear calmer after a hospital visit yet remain at risk if discharge information is incomplete or not handed over to the team who provide day-to-day care.

What should move with the resident or return with them

• Current concern: what changed, when, how quickly and what worried staff most.
• Baseline: how the resident normally thinks, moves, eats, drinks and communicates.
• Current plans: medicines list, allergies, escalation plans and relevant care plans.
• Family and contact details: who needs updating and what support the resident has.
• Discharge changes: new medicines, new monitoring, new restrictions, follow-up tasks and what still needs review.

Manager focus: transfer and return checks

Hospital transfer is safer when the person's baseline, the current concern and any return changes are handed over as clearly as the decision to send them.