Hospital Discharge Care Plan: Essential Guide

Hospitals must produce a written discharge care plan before discharge. If care needs are primarily health-driven, the NHS Continuing Healthcare programme may fund 100% of care costs with no means test — families who do not know this pay privately for care the NHS should cover.

TL;DR: NICE Guideline NG27 requires a written discharge care plan covering care needs, responsible services, equipment, emergency contacts, and the patient's own preferences — agreed before discharge. If needs are primarily health-driven, the NHS must also complete a CHC checklist. Around 60,000 people in England receive CHC at any one time (NHS England, 2023–24). Most families sign discharge paperwork before anyone mentions this right exists.

What must a hospital discharge care plan contain?

A discharge care plan is a formal document — not a verbal briefing from a nurse at the ward door. Where the care needs the plan documents are primarily health-driven, NHS Continuing Healthcare may fund 100% of ongoing costs with no means test — but only if an assessment has been requested. The plan must address five areas:

These five requirements are set out in the guideline governing hospital discharge for adults with social care needs (NICE guideline NG27, Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Needs, 2015).

Accordingly, the plan must be agreed with the patient and/or their representative before discharge takes place. A plan that is produced without discussion, handed over at the point of discharge, or that fails to address known care needs does not meet the requirements set out in that guideline (NICE Guideline NG27, 2015).

This matters beyond paperwork. From our casework, we've seen discharge teams routinely skip nursing needs in the care plan — pressure care, catheter management, complex medication regimes — and that omission can be used as evidence that the NHS failed to properly assess those needs. That, in turn, is relevant to whether an NHS Continuing Healthcare assessment should have taken place.

Your Legal Rights at Hospital Discharge

Several pieces of law and policy protect your relative at this stage. Therefore, understanding them changes what you can demand.

Patients have the right to be treated with dignity and respect and to receive care in a safe environment (NHS Constitution for England, 2023). Discharge must not only be clinically safe — it must also meet the person's social and care needs before they leave (NICE Guideline NG27, 2015).

Local authorities have a duty to carry out a needs assessment before care arrangements are made (Care Act 2014). That duty cannot be bypassed by a rushed discharge. A hospital cannot simply move a person out because a bed is needed.

Nevertheless, Section 2 notices — formerly referred to as "bed blocking" notices under the Community Care (Delayed Discharges etc.) Act 2003 — do not override the right to a safe discharge. They accelerate local authority assessment timelines but cannot force an unsafe discharge to happen.

A patient or their representative can challenge a discharge decision they believe is unsafe. You do not need to accept the hospital's timeline as fixed. The hospital cannot arrange an unsafe discharge for your relative. If you believe the discharge plan is inadequate, you can formally challenge it — and this page explains how.

What is a Discharge to Assess pathway and does it affect CHC?

Discharge to Assess (D2A) is a model used by many NHS trusts where the person is discharged to a temporary care setting — often a care home bed — for assessment, rather than remaining in hospital while needs are evaluated. It sounds administrative. Its financial consequences for families can be significant.

However, D2A does not remove the right to a CHC assessment:

• The CHC checklist can be completed by any registered nurse, including in the community or a temporary D2A placement
• A D2A placement is not the same as a permanent care home placement — the local authority funds it temporarily while needs are assessed
• If the CHC assessment is positive, the NHS takes over funding retrospectively from the date the primary health need began
• Families should not assume a D2A placement is automatically self-funded. It is not. The question of who ultimately pays depends on the CHC assessment outcome

If your relative is moved under D2A, request a CHC checklist assessment immediately in writing from the Integrated Care Board (ICB). Do not wait to see how the placement goes. The clock for retrospective funding starts from the point the primary health need was present — not from the point you asked for an assessment. Families who delay requesting an assessment while monitoring the placement lose weeks of potential retrospective coverage for every week they wait.

What should you do if the discharge care plan is inadequate?

You have identified gaps in the discharge care plan. Specifically, here are the practical steps to take, in order:

1. Ask for the written discharge care plan and read it in full. If it does not address all known care needs, note what is missing in writing. "The plan does not mention my mother's catheter care" is a specific, challengeable statement.
2. Raise the concerns with the ward nurse in charge and request a formal review. Put the request in writing — email is fine — and keep a copy. An email you sent creates a timestamp. A conversation in a corridor does not.
3. If you hold Lasting Power of Attorney for health and welfare, invoke that role explicitly and state that you do not consent to a discharge that does not meet your relative's assessed needs. LPA for health and welfare gives you legal standing to make this challenge.
4. Contact the hospital's Patient Advice and Liaison Service (PALS). PALS has a formal function to resolve discharge disputes before they escalate to complaints. They can convene a meeting between you, the discharge team, and the ward within days.
5. If discharge is imminent and you believe it is unsafe, contact NHS England's complaints team and your relative's GP in parallel. The GP has a clinical relationship with your relative and can raise concerns directly with the discharge team.

You do not need a solicitor to challenge a discharge plan. You need documentation, a clear statement of what is missing, and persistence.

Hospital Discharge and CHC Assessment Triggers

Hospital admission and discharge are the two most common points at which CHC assessments occur — and are most commonly missed. Ward teams are under pressure to discharge quickly. CHC assessments take time. Those two pressures work against each other, and families pay the difference.

The process works as follows:

• Any registered nurse or social worker involved in discharge planning can initiate the CHC checklist. This includes ward nurses, discharge coordinators, and community nurses — a GP referral is not required
• If the checklist is positive, a full multidisciplinary team (MDT) assessment must be completed within 28 days (NHS National Framework (2022))
• If the discharge team has not initiated the CHC checklist and you believe your relative has significant health needs, you can request one directly from the ICB
• Hospital admissions for people already living in care homes often reveal deterioration that should trigger a CHC reassessment. If your relative's condition has changed significantly since their last assessment, a new request is warranted

Consequently, around 60,000 people in England receive CHC funding at any one time (NHS Continuing Healthcare Statistics, 2023–24). The families of many more people who qualified never received it — because no one initiated the process at the point of hospital discharge.

What if the NHS refuses to assess for CHC at hospital discharge?

Refusal to initiate the CHC checklist at discharge is common. Where the person has clinical need, it may also be unlawful. The NHS has a legal obligation to screen for CHC eligibility at discharge — that obligation does not disappear because a ward is busy (National Framework for NHS Continuing Healthcare, 2022).

If the discharge team has not offered a CHC checklist and you believe your relative has a primary health need, take these steps:

• Write to the ICB directly and formally request a CHC checklist assessment. Cite the National Framework for NHS Continuing Healthcare (2022) and state that you believe your relative's needs should be assessed before discharge. A written request creates an obligation to respond
• If the ICB does not respond or refuses the checklist without adequate justification, escalate to NHS England
• If your relative has already been discharged and is now self-funding care that the NHS should have funded, a retrospective CHC assessment is possible. Families can request a retrospective review through NHS England for the period during which the primary health need was present

For instance, retrospective claims can cover months or years of care costs. The process is not straightforward, but it is available and families do recover significant sums through it. The starting point is establishing that the primary health need existed during the self-funded period — and this requires evidence. Gather clinical records, nursing assessments, GP letters, medication lists, and any discharge documentation from that time. A discharge care plan that was thin, incomplete, or that failed to trigger a CHC checklist is itself useful evidence. It demonstrates that the NHS did not assess properly at the time. That failure sits with the ICB, not the family — and the appeals process exists precisely to hold the NHS to account for it.