Synopsis
Plan safe, timely transfer from admission through shared assessment, medication reconciliation, functional and capacity review, equipment and care confirmation and accountable handover without making permanent placement decisions during reversible acute decline.
- Discharge planning starts on admission by establishing baseline, likely recovery, home circumstances, medicines, cognition, carer capacity and the person's goals.
- Being medically optimised does not mean functionally or socially safe; unresolved mobility, delirium, swallow, continence, equipment and night-care needs still require action.
- First-line readiness assessment confirms physiological stability, decision-making capacity, current function, destination access, support availability and a plan for likely deterioration.
- Use discharge-to-assess only when immediate destination is safe and the person can receive timely assessment; it must not become discharge without assessment or support.
- Do not make irreversible long-term care decisions solely from function during acute illness when rehabilitation and cognitive recovery remain plausible.
- Reconcile medicines against reliable pre-admission sources, remove inpatient-only treatment, explain changes and send indication, dose, duration, monitoring and pending results to the next prescriber.
- Confirm equipment, oxygen, dressings, continence supplies, nutrition, transport, access and prescriptions are physically available at the receiving setting.
- Ask unpaid carers privately what they can provide and offer carer assessment; family relationship does not guarantee consent, skill or overnight capacity.
- The person must know whom to call, which symptoms need urgent help and which team owns each follow-up, result and referral.
- A safe transfer closes the loop: receiving service acknowledges the handover, appointments and monitoring are booked and contradictory records are corrected.
Key red flags
New instability, oxygen need, delirium or acute pain before departure requires medical review and documented decision to proceed or cancel.
No safe access, food, heating, essential medicine or expected caregiver at the destination prevents discharge.
A patient who cannot understand the destination decision without a capacity and lawful decision process must not be transferred by convenience.
An unresolved safeguarding allegation or fear of someone at home requires private assessment and multi-agency planning.
Missing anticoagulant, insulin, steroid, antiseizure or opioid supply can cause serious harm within hours or days.
A temporary placement described to family as permanent without assessment or authority is misleading and unsafe.
An unassigned pending cancer, infection or imaging result creates a follow-up gap with potentially major consequence.
New hypoxia, hypotension, fever, chest pain, delirium, fall or loss of function requires reassessment and may cancel the planned transfer.
Investigation priorities
Confirm clinical stability, function, cognition, swallow, continence, devices, support, destination and patient goals before transfer.
Management branches
An older adult is admitted with illness or injury likely to affect function or support needs.
- Record stable baseline, home, medicines, cognition, communication, carers and goals and identify a coordinator and estimated pathway.
- Begin treatment, rehabilitation, equipment and care assessment together and update the person and chosen supporters as uncertainty changes.
- Identify capacity, safeguarding and housing barriers early enough for lawful resolution rather than discovering them on discharge day.