Discharge to Assess

Staffordshire and Stoke-on-Trent utilise a discharge to assess model within their health economy. This model supports the flow of the acute hospital and also promotes the fact that people are best assessed in their own home environment. Our focus centres on rehab and optimising people in a strengths-based way, i.e. using people’s social capital and relationship links to retain their independence at home.

The discharge model is in line with national legislation. On 1^st April 2022, new Discharge Guidance was issued. This new guidance replaces the previous Discharge Policy.

See: GOV.UK, Hospital discharge and community support guidance.

Our discharge model is split into four pathways:

• Pathway 0 supports simple and timely patients back to their own home either independently or with family support;
• Pathway 1 requires care and support however this is delivered at home and we will provide an assessment in someone’s own home environment;
• Pathway 2 is for bed-based rehab and is about optimising people so that they can hopefully return home after this short period of enablement;
• Pathway 3 can be for more dependent clients who require an assessment within a 24-hour care environment.

Each pathway is supported by a multi-agency approach including health (includes mental health), social care, and the voluntary sector who work collaboratively to identify those patients that fit into the complex pathways and support their progress through them.

Further information can be found in our Local Resources.

You can also see our Community Service Directory.

To find out more about minor adaptations and low-level equipment, see: Minor Adaptations and Low Level Equipment.