Discharge to Assess

The Discharge to Assess Model (D2A) aims to bridge the gap between hospital and home and means that people do not need to wait unnecessarily in hospital for full Social Care Assessments to be carried out and discharge from hospital is not delayed.  

D2A pathways provide a short-term period of assessment for people leaving hospital who have eligible care and support needs under the Care Act 2004. The assessment period can take place in a person’s own home with support and care services, in an Intermediate Care Rehabilitation Service or in a Care / Nursing Home depending on their immediate care and support needs.

The process embeds a ‘Home First’ approach to hospital discharge meaning that home should be the first consideration for people leaving hospital.  

The referral process for D2A is through a Trusted Assessment Document (TAD) that is completed with the person who has given consent, by a Therapist or Complex Case Manager working in the Hospital and begins when the person is first admitted. The TAD is then sent to BwD Intermediate Tier Service who have a multi-disciplinary team making the best and least restrictive decisions with a person about what service would be best placed to meet their needs. 

BwD Discharge to Assess services include:

Early Supported Discharge – This service supports people who have low-level therapy needs within their own home and which can be met by community therapy services.

Reablement – This service supports people with lower level physical care needs within their own home to promote their independence and identify appropriate support.

Home First Enhanced – This service supports people with more complex physical care needs with the input of Therapy Services within their own home to promote their independence and identify appropriate support.

Crisis Response – This service offers a short-term out of hours support service to people within their own home or a care home in a crisis. The team also provide an assessed night service to promote independence through an enablement approach.

Intermediate Care at Albion Mill – This service supports people who have intense therapy, rehabilitation or recovery needs which cannot be delivered in a person’s own home.

Discharge to Assess Residential Care – This service supports people who have physical care and support needs which cannot safely be delivered in a person’s own home. The assessment will be carried out whilst the person is staying in a 24/hour residential care setting. 

Discharge to Assess Nursing Care - This service supports people who have nursing led care and support needs which cannot safely be delivered in a person’s own home. The assessment will be carried out whilst the person staying in a 24/hour nursing care setting.