Hospital Discharge and community support Guidance
Annex B: discharge pathways
Pathway 0
Simple discharge home (to usual place of residence or temporary accommodation) co-ordinated by the ward without involvement of the care transfer hub, with:
• no new or additional health and/or social care and support
• self-management with signposting to services in the community
• voluntary sector support
• re-start of pre-existing home care package at the same level that remained active and on pause during the person’s hospital stay
• returning to original care home placement with care at the same level as prior to the person’s hospital stay
Pathway 1
Discharge home (to usual place of residence or temporary accommodation) with health and/or social care and support co-ordinated by the care transfer hub, including:
• home-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery at home
• re-start of home care package at the same level as a pre-existing package that lapsed
• returning to original care home placement with time-limited, short-term intermediate care
• long-term care and support at home following a period of intermediate care in the community
Pathway 2
Discharge co-ordinated through the care transfer hub to a community bedded setting with dedicated health and/or social care and support, including bed-based intermediate care on a time-limited, short-term basis for rehabilitation, reablement and recovery in a community bedded setting (bed in care home, community hospital or other bed-based rehabilitation facility).
Pathway 3
In rare circumstances, for those with the highest level of complex needs, discharge to a care home placement co-ordinated through the care transfer hub, including:
• care home placement for assessment of long-term or ongoing needs and facilitation of patient choice in relation to the permanent placement
• long-term care and support in a care home following a period of intermediate care in the community
