Transfers of care

Signposting resource

Published: August 2019

Delivering safe and timely transfers of care is a shared responsibility across the whole local health and social care system, including housing, private providers and the voluntary/community sectors.

All parties need to be at the table for both strategic and operational planning to ensure optimisation of effort.

There is no clear relationship between funding levels and the numbers of delayed transfers in different systems – therefore, local practice issues must play their part in performance. Systems that are more advanced on the integration journey have better performance in managing transfers of care.

• Key overarching resources Open

  • Better Care Exchange. The Better Care Exchange is a collaborative, social network for health and social care professionals. It enables networking, information and knowledge sharing on good practice for delivering better integrated care, and implementing Better Care Fund plans. In order to join the Exchange, you must work for or with local authorities, CCGs, or the NHS. To request access please email bettercareexchange@nhs.net with your name, job title, and organisation.
    Resources and case studies, Better Care Support Team

  • 2019–20 Better Care Fund Policy Framework
    Policy framework. Department of Health & Social Care, Ministry of Housing, Communities & Local Government

  • Better transfers of care for older people – conference (February 2017)
    Presentations. King’s Fund

  • Delayed discharge: ‘It’s not just about the money’
    Article. King’s Fund

  • High impact change model
    Toolkit. Local Government Association and NHS

  • Integrated care value case toolkit
    Toolkit. Local Government Association

  • Integration and the Better Care Fund
    Tools and resources. Local Government Association

  • Integration: delivering better outcomes for citizens and communities – the 2016/17 care and health improvement programme
    Tools and resources. Local Government Association

  • Stepping up to the place: integration self-assessment tool (2016)
    Toolkit. Local Government Association

  • Simple guide to the Care Act and delayed transfers of care (DTOC)
    Guide. Local Government Association, University of Birmingham, Association of Directors of Adult Social Services and Think Local Act Personal

  • Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NG27). See also the associated costing statementand the scope which has useful contextual information.
    Guide. National Institute for Health and Care Excellence

  • Better use of care at home (October 2015)
    Quick guide. NHS England

  • Identifying local care home placements (October 2015)
    Quick guide. NHS England

  • Sharing patient information (October 2015)
    Quick guide. NHS England

  • Transforming urgent and emergency care services in England. Safer, faster, better: good practice in delivering urgent and emergency care – A guide for local health and social care communities (Keogh urgent care review)
    Guide. NHS England

  • Safer, better, faster care for patients
    Webinars. NHS Improvement

  • Elective care
    Resources. NHS Improvement

  • Emergency care
    Resources. NHS Improvement

  • Right place, right time: better transfers of care
    Report. NHS Providers

  • Integrated care – taking specialist medical care beyond the hospital walls
    Report. Royal College of Physicians

  • Delivering integrated care masterclasses (2017)

    • Sharing responsibility for transfers of care
    • Measuring success
    • Sharing risk and benefits

    Presentations, models and case examples. Better Care Support Team and Social Care Institute for Excellence

  • Integrated health and social care 2020: research
    Research study. Social Care Institute for Excellence

  • Prevention and wellbeing
    Case studies and resources. Social Care Institute for Excellence

  • Stepping up to the place – A review of the vision
    Report. Institute of Public Care

  • Why not home, why not today? Putting a stop to DTOC (November 2017)
    Report. LGA (Newton Europe)

  • Care and Health Improvement Programme: Integration support offer for health and care system leaders (November 2018)
    Tools and Resources. LGA

  • Shifting the centre of gravity: Making place-based, person-centred health and care a reality (November 2018)
    Toolkit. LGA et al

  • Delayed transfers of care: A quick guide (January 2018)
    Article. King's Fund

  • Discharging older people from hospital (2016)
    Report. National Audit Office

  • People first, manage what matters (2019)
    Report. Newton Europe

  • Quick Guides: Transforming urgent and emergency care services in England (December 2017)
    Guidance. NHSE et al

  • Better Care Fund: 2018/19 planning data (November 2018)
    Report. NHSE/Better Care Support Team

  • Shared decision making: Summary guide (January 2019)
    Guidance. NHSE

  • Discharging older people from acute hospital (July 2016)
    Inquiry. UK Parliament

  • Top Tips for working safely in escalation in the urgent care system when increasing bed availability through fast track discharge (Sept 2018)
    Guidance. ADASS

• Person-centred, coordinated care - resources Open

  Preventing hospital admissions and ensuring safe, timely transfers of care is dependent on agencies coordinating care around the needs of the person. This enables informed choice for the individual and meaningful integration of services. Promoting personal independence and self-care through asset-based approaches and engagement with the public is essential to improving health and preventing hospital admissions, as well as promoting successful transfers of care.

  • Guidance for NHS continuing healthcare assessors - Evaluating emotional and psychological needs for people in the later stages of dementia
    Guide. Alzheimer’s Society

  • Understanding safe discharge of patients with dementia from the acute hospital
    Article. British Journal of Hospital Medicine

  • Ideas into action: person-centred care in practice. What to consider when implementing shared decision making and selfmanagement support
    Toolkit. Health Foundation

  • My discharge - a proactive case management for discharging patients with dementia
    Case study report. Health Foundation

  • Person-centred care made simple. What everyone should know about person-centred care
    Toolkit. Health Foundation

  • Guidance for commissioners of liaison mental health services to acute hospitals
    Guide. Joint Commissioning Panel for Mental Health

  • Patients experience of using hospital services – December 2015
    Report. King’s Fund and the Picker Institute

  • Personalised care and support planning handbook: The journey to person-centred care. Core Information
    Guide. NHS England

  • Working together 2: Easy steps to improve support for people with learning disabilities in hospital. Guidance for hospitals, families and paid support staff
    Guide. Public Health England

  • Personalised care and support planning
    Toolkit. Think Local Act Personal

  • A narrative for person-centred coordinated care
    Guide. Think Local Act Personal and National Voices

  • Prevention and wellbeing
    Case studies and resources. Social Care Institute for Excellence

  • Person-centred care
    Resources. Social Care Institute for Excellence

  • High impact change model: Managing transfers of care between hospital and home (July 2017)
    Toolkit. LGA and others

  • Keep safe, stay well and remain independent: Windsor, Ascot and Maidenhead CCG (November 2017)
    Case study. NHS England

• Carers and family members - resources Open

  It is crucial that carers and family members are fully engaged as equal partners in the discharge planning process. They need clear written information at the point of admission which explains the estimated date of discharge, the choice protocol and the ‘home first’ policy including discharge to assess schemes. Carers’ own needs must be taken into consideration and the information provided should always include the offer of a carer’s assessment.

  • Going into hospital
    Information. Alzheimer’s Society

  • Coming out of hospital
    Fact sheet. Carers UK

  • Hospital discharge planning: A guide for families and caregivers
    Guidance. Family Caregiver Alliance

  • Patient and family centres care toolkit (May 2014)
    Toolkit. King’s Fund

  • People in control of their own health and care – the state of involvement (November 2014)
    Report. King’s Fund

  • Understanding and improving transitions of older people: a user and carer centred approach
    Report. National Institute for Health Research

  • Pressure points: Carers and the NHS (September 2016)
    Report. Carers UK

  • Patient experience improvement framework (January 2019)
    Guidance. NHS Improvement

  • Partnership working with health service users (January 2018)
    Toolkit. NHS Improvement

  • Reducing length of stay (January 2018)
    Toolkit. NHS Improvement

• Community, including support to care homes - resources Open

  Community and voluntary sector resources can play a key role as part of an integrated support plan in helping people safely transfer home and remain at home, by tackling issues such as social isolation. Bespoke health and social care input to care homes also makes an important contribution to reducing unnecessary hospital admissions and facilitating transfers of care.

  • How to... work together to achieve better joined-up care - August 2019
    Guide. Better Care Support Team

  • Hospital 2 home resource pack
    Toolkit. Housing Learning and Improvement Network

  • Combating loneliness – A guide for local authorities (January 2016)
    Guide. Local Government Association

  • NICE SC1 Managing medicines in care homes (including support for commissioning and a checklist for care home medicines policy)
    Guide. National Institute for Health and Care Excellence

  • Continuing healthcare
    Framework and regulations. NHS England

  • Better use of care at home (October 2015)
    Guide. NHS England

  • Clinical input into care homes (October 2015)
    Guide. NHS England

  • Identifying local care home placements (October 2015)
    Guide. NHS England

  • Improving hospital discharge into the care sector (October 2015)
    Guide. NHS England

  • Technology in care homes (October 2015)
    Guide. NHS England

  • The framework for enhanced health in care homes (September 2016)
    Framework. NHS England

  • Working with the voluntary and community sector: A guide for health and wellbeing boards
    Guidance. Regional Voices

  • Asset-based places: a model for development
    Model and case studies. Social Care Institute for Excellence

  • Strength-based approaches
    Model. Social Care Institute for Excellence

  • Intermediate care
    Research and case studies. Social Care Institute for Excellence

  • Developing the power of strong, inclusive communities
    Toolkit. Think Local Act Personal

  • Admissions to residential and nursing care from hospital and delayed transfers of care (2018)
    Advice note. ADASS

  • Enhanced health in care homes (December 2017)
    Report. King’s Fund

  • Framework for maximising the use of care homes and use of therapy-led units for patients medically fit for discharge (December 2017)
    Guidance. NHS England

  • How a simple red bag improved care for care home resident Patricia (June 2018)
    Case study. NHS England

  • Quick Guide: Hospital transfer pathway – ‘Red Bag’ (June 2018)
    Guidance. NHS England

  • Pioneering home alteration project between NHS and Council helps get people home from hospital sooner (Aug 2018)
    Case Study. NHS England

• Management of patient flow - resources Open

  There are many good practice examples of how hospitals are optimally managing the patient journey through the hospital, from admission to timely discharge. These include use of the SAFER patient flow bundle, which all acute hospitals should now be implementing, together with the introduction of integrated discharge teams and ‘home first’ models such as trusted assessor and discharge to assess.

  • Developing a home first mindset
    Guide. Academy of Fabulous NHS Stuff

  • Personalised integrated care programme
    Case study. Age UK

  • Delivering integrated care masterclasses (2017)

    • Sharing responsibility for transfers of care
    • Measuring success
    • Sharing risk and benefits

    Presentations, models and case examples. Better Care Support Team

  • Urgent and emergency care – integrated ‘discharge to assess’ model reduces admissions to hospital
    Case study. Doncaster Metropolitan Borough Council, Rotherham, Doncaster and South Humber NHS Foundation Trust and Doncaster and Bassetlaw NHS Foundation Trust

  • Lincolnshire Care Home Trusted Assessor Project
    Case study. Emergency Care Improvement Programme

  • Safer clinical systems: East Kent Hospitals University NHS Foundation Trust
    Sharing responsibility for transfers of care. Health Foundation

  • Housing and adult social care 2015
    Measuring success. Institute of Public Care

  • Better transfers of care for older people – conference (February 2017)
    Sharing risk and benefits. King’s Fund

  • High impact change model
    Toolkit. Local Government Association et al.

  • Moving health care closer to home case studies: Enabling early discharge
    Case studies. Monitor

  • Discharge case study: the Ipswich Hospital NHS Trust
    Case study. NHS England

  • Discharge to assess: quick guide (2016)
    Guide. NHS England

  • Health and housing: quick guide (October 2016)
    Guide. NHS England

  • Improving hospital discharge into the care sector
    Guide. NHS England

  • Rapid improvement guide: SAFER patient flow bundle
    Guide. NHS Improvement

  • What’s behind delayed transfers of care? (2017)
    Briefing. Nuffield Trust

  • Discharge case study – University Hospitals Birmingham NHS Foundation Trust
    Case study. University Hospitals Birmingham NHS Foundation Trust

  • Improving patient flow(Sheffield Teaching Hospital NHS Trust and South Warwickshire NHS Foundation Trust)
    Sharing responsibility for transfers of care. Health Foundation

  • Refer to pharmacy: Dedicated ward pharmacy model (August 2016)
    Case study. NHS Providers

  • No hospital is an island – learning from the acute care collaborations (January 2018)
    Report. NHS England

  • Good practice guide: focus on improving patient flow (July 2017)
    Guidance. NHS Improvement

  • Developing trusted assessment schemes: Essential elements (July 2017)
    Guidance. NHS Improvement

  • The SAFER patient flow bundle and Red2Green days approach – Criteria led discharge (September 2017)
    Guidance. NHS Improvement

  • Rapid Improvement Guide: Red2Green bed days (2017)
    Guidance. NHS Improvement

  • Red2Green Improvement Tool (March 2018)
    Toolkit. NHS Improvement

  • Sheffield Teaching Hospitals NHS Foundation Trust: Red2Green (November 2018)
    Case study. NHS Improvement

  • Discharge planning (January 2018)
    Guidance. NHS Improvement

  • Flow – reducing unnecessary waits (January 2018)
    Toolkit. NHS Improvement

  • Sharing Best Practice: Improving patient flow within local services (January 2018)
    Case Study. NHS Improvement

  • Implementing seven day hospital services (March 2018)
    Case Studies. NHS Improvement

  • Managing increased demand from winter illness (June 2018)
    Guidance. NHS Improvement

  • Complex recovery assessment and consultation team: ensuring people with complex needs are not stranded in the system (October 2018)
    Case study. NHS Improvement

  • Discharge to assess: Home in a day (October 2018)
    Case study. NHS Improvement

  • Emergency Flow Improvement Tool (February 2019)
    Toolkit. NHS Improvement

  • Delayed transfer of care (DTOC) Improvement Tool (February 2019)
    Toolkit. NHS Improvement

• Diverse and sustainable provider market through integrated commissioning - resources Open

  Integrated health and social care market shaping and commissioning (including a co-produced joint market position statement) is more likely to create conditions for innovative and sustainable community-based services, as well as ensure sufficient access to residential and nursing care places. Workforce planning across the whole system, including the voluntary and private sectors, is a key element in ensuring successful integrated commissioning.

  • How to... bring budgets together and use them to develop coordinated care provision - August 2019
    . Better Care Support Team

  • Sharing risks and benefits of integrated care: quick guide - August 2019
    . Better Care Support Team

  • Think integration, think workforce: three steps to workforce integration
    Guide. Centre for Workforce Intelligence

  • Market position statement guidance – July 2016
    Guide. Institute of Public Care

  • Market shaping review: what is market shaping?
    Guide. Institute of Public Care

  • Market shaping toolkit (MaST): supporting local authority and SME care provider innovation and collaboration market shaping
    Toolkit. Institute of Public Care

  • Place-based market shaping – coordinated health and social care (July 2016)
    Guide. Institute of Public Care

  • Options for integrated commissioning – beyond Barker (June 2015)
    Report. Kings Fund

  • Supporting integration through new roles and working across boundaries – June 2016
    Report. Kings Fund

  • Commissioning for better health outcomes (September 2016)
    Guide and case studies. Local Government Association

  • Commissioning for better outcomes: A route map (2015)
    Resource. Local Government Association, University of Birmingham, Association of Directors of Adult Social Services and Think Local Act Personal

  • The principles of workforce integration
    Guide. Skills for Care

  • Working together: a summary of health and social care integration projects
    Case studies. Skills for Health

  • People not process – co-production in commissioning and market shaping
    Guide. Think Local Act Personal

  • Social care market sustainability (July 2015)
    Guidance and toolkit. Cordis Bright

  • Integrated commissioning for better outcomes: A commissioning framework (April 2018)
    Tool. LGA and NHS Clinical Commissioners

  • Market shaping in adult social care (August 2017)
    Paper. Institute of Public Care

  • Reducing delays in hospital transfers of care for older people: Key messages in planning and commissioning (September 2018)
    Report. Institute of Public Care (Professor John Bolton)

  • Published case studies relating to commissioning and market shaping for adult social care
    Case studies. LGA

  • Developing People Improving Care: Short Guides (February 2019)
    Guidance. NHS Improvement

  • Care homes market study summary of final report (November 2017)
    Guidance. Competition and Markets Authority

• Effective systems - resources Open

  Metrics should enable early identification of risk across the whole health and social care system (i.e. capacity and demand issues). Where appropriate, selection of alternative metrics should be considered as a means of setting local priorities for change. A key metric should be developed from asking people about their experience of the patient journey through the hospital, and should include satisfaction with their transfer arrangements.

  • Creating ‘predictable recovery for the emergency pathway’ (PREP)
    Resources. Academy of Fabulous NHS Stuff

  • Delivering integrated care masterclasses (2017)

    • Sharing responsibility for transfers of care
    • Measuring success
    • Sharing risk and benefits

    Presentations, models and case studies. Better Care Support Team

  • How to... understand and measure impact (August 2019)
    Guide. Better Care Support Team

  • Discharge to assess – September 2016
    Measuring success. NHS England

  • Transforming urgent and emergency care services in England – safer, faster, better: good practice in delivering urgent and emergency care. A guide for local health and social care communities (August 2015)
    Sharing risk and benefits. NHS England

  • Moving health care closer to home (September 2015)
    Case studies. NHS Monitor

  • Improving length of stay: what can hospitals do? 
    Research report. Nuffield Trust

  • Integration 2020
    Research. Social Care Institute for Excellence

  • Winter pressures, monthly delayed transfers of care
    Tools. LGA – LG Inform

  • Delayed transfers of care
    Overview. LGA – LG Inform

  • Monthly delayed transfers of care: Situation report
    Principles, definitions and guidance. NHS England

• Strong and empowering leadership - resources Open

  Strong and empowering system leadership is essential for agencies to take full ownership of sharing responsibility for transfers of care. Deficits in system leadership, silo working and a disconnect between strategic leaders and operational managers are factors perceived to particularly influence performance on transfers of care.

  • How to... lead and manage better care - August 2019
    Guide. Better Care Support Team

  • The revolution will be improvised Part 2
    Guide. The Leadership Centre (LGA)

  • Caring to change – how compassionate leadership can stimulate innovation in health care (May 2017)
    Case studies. King’s Fund

  • The practice of system leadership – Being comfortable with chaos (May 2017)
    Case studies. King’s Fund

  • Leadership
    Resources. Local Government Association

  • Care and Health Improvement Programme: Integration support offer for health and care system leaders
    Toolkit.

  • Sector-led improvement in health and social care (2015)
    Resource. Local Government Association – Towards Excellence in Adult Social Care

  • Supporting leaders to deliver transformational change (April 2017)
    Article. King’s Fund (Nicola Walsh)

• Integrated health and social care - resources Open

  The cornerstone for avoiding hospital admission and ensuring safe, timely discharge is integrated health and social care services available 24/7. These must be responsive to individual needs and support people to maximise their independence and manage their own health in the community. These services should actively engage with people living in care homes.

  • Acute hospitals and integrated care – from hospitals to health systems (March 2015)
    Case studies. King’s Fund

  • Supporting People to manage their own health – An introduction to patient activation (May 2014)
    Guidance. King’s Fund

  • Helping people look after themselves: A guide on self care (October 2016)
    Local Government Association. Case studies

  • Just what the doctor ordered: social prescribing – a guide for local authorities (May 2016)
    Guide. Local Government Association

  • Public health’s role in local government and integration (July 2016)
    Report. Local Government Association

  • Sustainability and transformation plans (STPs): How do you know if STPs are making a positive impact (February 2017)
    Report. Local Government Association

  • The journey to integration: learning from the seven leading localities (May 2016)
    Case studies. Local Government Association

  • Public Health working with the voluntary, community and social enterprise sector: new opportunities and sustainable change (March 2017)
    Case studies. Local Government Association and Volunteering Matters

  • Mental wellbeing of older people in care homes
    Guide. National Institute for Health and Care Excellence

  • NICE SC1 Managing medicines in care homes (including support for commissioning and a checklist for care home medicines policy)
    Guide. National Institute for Health and Care Excellence

  • Right place, right time, right team – Thurrock rapid response assessment service
    Case study. North East London NHS Foundation Trust

  • Clinical input into care homes
    Guide. NHS England

  • Transforming urgent and emergency care services in England. Safer, faster, better: good practice in delivering urgent and emergency care – A guide for local health and social care communities (Keogh urgent care review)
    Guide. NHS England

  • Avoiding unnecessary hospital admissions videos
    Videos. Social Care Institute for Excellence

  • Outcomes-focused integrated care: lessons from experience (January 2017)
    Paper. Institute of Public Care

  • Breaking down barriers to better health and care (June 2018)
    Report. NHS England

• Contributors Open

  We would like to thank the following individuals for their contribution to this publication:

  Edition 2 (August 2019)

  • Hannah Miller, Senior Associate, SCIE
  • Carmen Colomina, Practice Development Manager, SCIE
  • Shirish Gandhi, Publishing Manager, SCIE
  • Iris Steen, Head of Communications, SCIE

  Edition 1 (March 2016)

  • Sharon Boundy, Programme Lead for Transformation, Frimley Health NHS Foundation Trust
  • Emma Brown Manager, KPMG
  • Charlotte Buckley , Deputy Director, People, Communities and Local Government, Department of Heath
  • Tina Coldham , Chair of Co-Production Network, SCIE
  • Andrew Cozens , Better Care Advisor, Better Care Advisor
  • David Cundy , Head of Delivery, SCIE
  • Robin Firth , Senior Delivery Advisor, Department of Health
  • Deborah Glastonbury , Chief Operations Manager – Integration, UCL Hospital NHS Foundation Trust
  • Anne Hackett , Local Insight and Resilience Branch, Department of Health
  • Tony Hunter , Chief Executive, SCIE
  • Heidi Ilsely , Head of Adult Services, Wokingham Berkshire NHS Foundation Trust
  • Sandie Keene , Care and Health Improvement Advisor, Local Government Association
  • Ewan King , Head of Business Development and Delivery, SCIE
  • Hannah Miller , Senior Associate, SCIE
  • Sarah Mitchell , Director, Towards Excellence in Adult Social Care
  • Phil McCarvill , Deputy Director of Policy, NHS Confederation
  • Alice Moore , Strategic Development Manager, BUPA
  • David Pearson , Corporate Director of Adult Social Care and Health, Nottinghamshire County Council
  • Mike Potts , Consultant
  • Dame Philippa Russell , Emeritus Chair, Standing Commission on Carers
  • Elizabeth Sargeant , Clinical Lead (Integration) - Emergency Care Improvement Programme, NHS England
  • Rosie Seymour , Deputy Programme Director - Better Care Support Team, NHS England
  • Tom Shakespeare , Senior Advisor - Better Care Support Team, Local Government Association
  • Debbie Sorkin , National Director of Systems Leadership, The Leadership Centre
  • Reva Stewart , Head of Adult Services, Reading Berkshire NHS Foundation Trust
  • Ian Turner , Chair, Registered Nursing Homes Association
  • Andrew Webster , Director - Public Sector, KPMG
  • Fiona Williams, Director of Operations, Bluebird Care Group