Hospital referral for assessment for community care and support

Hospitals must determine when it is safe to discharge a person and implement a discharge plan. Part of that decision-making process requires hospital staff to determine whether the person needs to be referred for an assessment to establish ongoing care and support in the community after discharge.

This standard supports the communication between hospital staff and community and social care staff where it is decided that a referral for assessment is needed. 

Current release

Version: V1.1
Release date
April 2021
Release notes
V1.1 release notes
Next release date
December 2025 – TBC
Next release type
Standard 3-year review
The standard
Full standard – PRSB viewer
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Supporting documentation
Description/purpose
Information standards notice (ISN)
ISNs are published to announce new or changes to information standards published under section 250 of the Health and Social Care Act 2012.
Implementation guidance
This document includes general implementation guidance for all PRSB standards and detailed guidance, specific to this standard.
Digital social care final report
Describes the purpose, methodolgy and stakeholder engagement for developing the standard, along with the findings and recommendations for further work.
Survey 2 Report
Survey report detailing findings from the consultation phase of the project.
Safety case report
Summarises the hazards which could result from implementing the standard.
Hazard log
Details the potential hazards from implementing the standard with their risk rating and mitigation.
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About this standard

The Hospital Referral for Assessment for Community Care and Support standard defines the information requirements in respect of an adult person being referred from hospital to health and social care for possible ongoing social and health care support following discharge from hospital. 

The standard includes the minimum information that previously had be sent to the person’s local authority as part of the Assessment, Discharge and Withdrawal Standard notice(s) (SCCI2075) which is now retired as well as the clinical information that health and social care professionals in the community have told us they require following discharge from hospital.  

Benefits: 

  • Enhances professional communication and continuity of care. 
  • Ensures timely access to relevant patient information. 
  • Supports integrated care between acute, social and community care. 

Scope

The Hospital Referral for Assessment for Community Care and Support standard is:

  • a definition of the information to be shared with the responsible body when referring an adult for assessment for care and support by social services and/ or NHS services after discharge from an acute hospital
  • applicable to individuals who require care and support, after discharge, in their own home or if placed in an accommodation setting such as a care home.
  • supportive of and is an integral part of the discharge planning and process for these individuals.
  • supportive of the information elements that are needed to extract ADW notices to the local authority.
  • IT system and discharge pathway agnostic.
  • compliant with Care Act 2014 discharge pathway information requirements.
  • compatible with the Discharge to Assess process.

 

What is not in scope

  • the discharge processes themselves
  • all the referral information required for a person discharged from a mental health service because it is developed for a person who has received care in an acute hospital
  • adults who do not need care and support after discharge from hospital
  • people who wish to make private arrangements for care and support without the involvement of the local authority (it is recognised the local authority may still become involved for self-funded persons)
  • a definition of how information should be presented to professionals.

How it works

The standard includes a core set of information that is communicated in the referral and references other important documents pertaining to the person that should be accessible. These additional documents may be communicated as attachments or be available from shared care records. For example, if an end of life care plan exists it is important that this is communicated in the referral and the recipient is sent the document or knows where to access it.

The diagram below shows the documentation that might be available in a shared care record and not communicated with the referral. Please click on the diagram image to open a full screen version.

Further resources

  • Standards explained
    PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them.
 
 

Endorsement

  • British Association for Music Therapy
  • British Dietetic Association
  • British Geriatrics Society
  • British Psychological Society
  • Care Provider Alliance
  • Care Software Providers Association (CASPA)
  • Chartered Society of Physiotherapy
  • Compassion in Dying
  • Health and Social Care Alliance Scotland
  • Institute of Health Records and Information Management
  • Local Government Association
  • Royal College of Emergency Medicine
  • Royal College of General Practitioners
  • Royal College of Nursing
  • Royal College of Occupational Therapists
  • Royal College of Physicians
  • Royal Pharmaceutical Society