Adult Social Care Glossary, v 0.6

Pathways for the discharge to assess model

(Adapted from John Bolton model for persons aged 65 and over, and when used across all 18+ age groups, it is expected that a greater percentage than detailed will be allocated to pathways 0 and 1.)

Pathway 0 (likely to be minimum of 50% of people discharged): simple discharge home

- no new or additional support is required to get the person home or such support constitutes only:
- informal input from support agencies
- a continuation of an existing health or social care support package that remained active while the person was in hospital

Pathway 1 (likely to be minimum of 45% of people discharged): able to return home with new, additional or a restarted package of support from health and/or social care. This includes people requiring intensive support or 24-hour care at home.

- Every effort should be made to follow home first principles, allowing people to recover, reable, rehabilitate or die in their own home.

Pathway 2 (likely to be maximum of 4% of people discharged): recovery, rehabilitation, assessment, care planning or short-term intensive support in a 24-hour bed-based setting, before returning home.

Pathway 3 (for people who require bed-based 24-hour care): includes people discharged to a care home for the first time (likely to be a maximum of 1% of people discharged) plus existing care home residents returning to their care setting (for national data monitoring purposes, returning care home residents will count towards the 50% figure for pathway 0).

Those discharged to a care home for the first time will have such complex needs that they are likely to require 24-hour bedded care on an ongoing basis following an assessment of their long-term care needs.

If you are ready to leave hospital but still need some care and support, you may be able to go home with care provided in your home for a short period while discussions take place about the care and support you may need in the longer term. This means you can continue your recovery at home, rather than having to stay in hospital while your future support is worked out. It also means that your needs can be assessed in your own home, where you may be able to do things for yourself differently than in hospital.

This guidance sets out how NHS bodies (including commissioning bodies, NHS trusts and NHS foundation trusts) and local authorities can plan and deliver hospital discharge and recovery services from acute and community hospital settings that are affordable within existing budgets available to NHS commissioners and local authorities. It applies to NHS bodies and local authorities exercising health and adult social care functions in England and should be used to inform local service planning and delivery.

This guidance applies in relation to adults being discharged from acute hospitals and community rehabilitation units in England, excluding maternity patients.

Discharges from mental health hospitals are not within the scope of this guidance. However mental health trusts are encouraged to embed some of the principles, adapted for mental health care pathways. Separate guidance will be published for those being discharged from mental health settings in due course.

This guidance is applicable from 1 April 2022.