Improving the effective hospital discharge of people into the community
Discharge from hospital is a critical transition point in the care journey – especially for people living with dementia or experiencing delirium.
Poorly coordinated discharge can lead to worse health outcomes, disorientation, readmission, and increased pressure on families and carers.
With an ageing population and rising complexity of need, councils and health partners must work together to create smoother pathways that promote recovery, independence, and stability.
The Better Care Fund (BCF) Support Programme has delivered a wide range of improvement support and interventions to health and social care systems, both at integrated care board and place level, to overcome some of the main challenges in delivering integrated, effective, person-centred health and care services, and embed sustainable solutions. It has been extended by one year to March 2026.
BCF’s new High Impact Change Model (HICM) offers a practical framework to help health and care systems improve the timely and effective discharge of people with dementia and delirium into the community.
The HICM draws on learning from across health and care systems and presents eight evidence-based changes that can help reduce delays, improve person-centred outcomes, and make better use of resources.
The model recognises that no single intervention will solve the issue of delayed discharge.
Instead, it provides a holistic approach that places the person at the centre – taking into account the clinical, emotional and practical support they need before, during and after leaving hospital.
Each of the eight high-impact changes addresses a key area of focus, from shared decision-making and pre-discharge planning to follow-up support in the community and carer involvement.
The model also highlights the importance of workforce training, access to dementia-specific expertise, and the role of integrated commissioning in achieving better outcomes.
To support implementation, the model is accompanied by a series of case studies showcasing real-life examples from health and care systems across England.
These include examples of enhanced discharge teams, targeted dementia pathways, and community reablement services that provide wraparound care and help prevent avoidable readmissions.
For instance, one featured local area has introduced dementia discharge coordinators within acute settings to support families and ensure that personalised care plans are in place prior to discharge.
Another area has embedded a delirium screening tool and rapid-response team into emergency departments, leading to faster diagnosis and more appropriate onward care.
Improving discharge for people with dementia and delirium is a shared challenge across councils, NHS partners and the voluntary sector.
The new HICM is designed to help systems assess their current approach, identify gaps and opportunities, and take coordinated action.
Councils, integrated care systems and providers can access the full model and supporting resources via the LGA website. The model includes a downloadable change model, diagnostic tool, and implementation guide.
Better Care Fund Support Programme
The 2023-2025 Better Care Fund Support Programme, delivered by the LGA, the Association of Directors of Adult Social Services and consultants Newton, and funded by government, helped local systems deliver integration of health, social care and housing in a way that supports person-centred care, sustainability and better outcomes for people and carers; and enhanced the range of support and interventions available to help overcome some of the main challenges in delivering integrated and sustainable health and care support.