Advice and guidance on discharging COVID-19 positive patients to care homes

Timely discharge benefits the hospital, but most importantly, the patient. A longer stay in hospital increases the risk of falls, depression, hospital-acquired infection and other negative outcomes. We have identified the key points in advice and guidance from the UK governments, NHS and elsewhere. It is likely to be regularly updated, so while we aim to keep members up to date, we also urge them to keep a careful watch for new and revised policies.

The main points are that:

• Patients should be discharged as soon as they are fit, whether they are COVID-19 positive or not.
• COVID-19-positive patients being discharged into a care home setting can only be discharged into care homes that have been designated safe by the relevant regulatory body. If their own care home is not COVID-19-safe, they need to be discharged into alternative accommodation.
• It is the responsibility of the local authority to find alternative accommodation.

Cooperation between secondary and primary healthcare providers, the care home sector and other care providers – such as community palliative and hospice care – and local authorities is crucial. These collaborations should also have a long-term benefit, helping to improve medical care for care home residents by strengthening relationships between all those who provide them with care.

Hospital staff should talk to care home staff about the estimated date of discharge as soon as possible after admission and diagnosis of COVID-19. This conversation should include the date and result of the first swab and the planned date of pre-discharge swab.

If the care home cannot accept COVID-19-positive patients, the hospital should contact the local authority immediately about alternative accommodation. Ward-based staff should keep the patient, carers and any relatives and friends informed about all discussions.

England

In April 2020, the Department for Health and Social Care (DHSC) published the Coronavirus (COVID-19): adult social care action plan. That was followed in July by Guidance for stepdown of infection control precautions and discharging COVID-19 patients, which includes discharge to a single occupancy room in a care facility, including nursing homes and residential homes.

On 15 September 2020, the Association of Directors of Adult Social Services (ADASS) published Cohorting, Zoning and Isolation Practice – Commissioning for Resilient Care Home Provision. The following day the Hospital discharge service: policy and operating model was updated by DHSC. It includes:

• actions for acute care organisations and staff
• actions for care providers
• admission and care of people in care homes, including a section on isolation of residents discharged from hospital or another social care facility.

The DHSC winter plan to help protect care homes was published on 18 September 2020. The British Geriatrics Society has published COVID-19: Managing the COVID-19 pandemic in care homes for older people and is updating it as necessary.

On 21 October 2020, the DHSC published a letter to local authority directors of adult services laying out information on designated care settings.

Key points

• Hospital discharge service: action cards summarise the responsibilities of health and care staff in the hospital discharge process. The main message for doctors is that all people who no longer meet the criteria to reside for inpatient care in acute hospitals should be discharged home or to a non-acute setting.
• All patients planned for discharge to a care home need to have a COVID-19 swab test 48 hours prior to their planned discharge date. The result must be communicated to the care home before the patient leaves the hospital, unless otherwise agreed with the care home.
• Patients can and should be discharged before resolution of symptoms, provided they are deemed clinically fit for discharge in a rapid, but safe, manner.
• COVID-19-positive patients being discharged into a care home setting can only be discharged into care homes that have been designated safe by the Care Quality Commission (CQC). If their own care home is not COVID-19-safe, they need to be discharged into alternative accommodation.
• If a care home cannot accept a COVID-19-positive person, the local authority should be contacted as soon as possible. It is responsible for working with the clinical commissioning group (CCG) to provide alternative accommodation locally. Discharge funding has been made available via the NHS to cover the costs of providing alternative accommodation, as well as continuing support services such as rehabilitation and reablement.
• Hospitals must work with their local authorities to ensure that all relevant stakeholders are aware of where additional capacity is held for such residents, and how to access it urgently. This will require careful communication and messaging.

Wales

In April, the Welsh government published the COVID-19 Hospital Discharge Service Requirements (Wales). The guidance sets out the hospital discharge services requirements for health, social care, and third and independent sector partners in Wales, and the actions that must be taken to enhance discharge arrangements and the provision of community support. This was followed by an update to the step-up and step-down care arrangements guidance on 29 April 2020.

A revised reporting template was sent to health boards on 4 May 2020.

In October 2020, RCP fellows raised concerns about a breakdown in patient flow and good communications between hospitals and the social care sector in some parts of Wales. The vice president for Wales, Dr Olwen Williams, issued a statement calling for a review of COVID-19 discharge guidance on 29 October 2020.

As a result of this intervention, the Welsh government published a written statement on 15 December 2020: Discharge arrangements and duration of Covid outbreaks in social care, alongside new scientific advice from the Technical Advisory Group: Updated consensus statement on recommended testing criteria for discharge of asymptomatic patients to care homes.

Key points

• The new guidance is based on the principle of ‘home first’, the Discharge to Recover then Assess pathways and a collective focus on rehabilitation and reablement.
• People with a negative COVID-19 test, or a test with a Ct number of 35 or above, may be discharged to home or a social care setting. This will be on the provision that the other criteria of 14 days has elapsed since the last positive test or onset of symptoms, the person has been free from fever for 3 days, and other symptoms have shown improvement, are all met.
• Patients who are infectious, but no longer need acute care, should move to a COVID-infectious step-down facility. This applies to patients who have had COVID-19; for patients who have not had evidence of COVID-19, the current requirements for a negative test prior to discharge and an isolation period will remain in place.
• Multi-disciplinary teams, having taken into account the specific circumstances of individual homes, will be allowed to declare that outbreaks are over after 20 days have elapsed since the last positive test or manifestation of symptoms. This modification of the current 28-day requirement will be subject to a confirmatory round of negative or low positive (Ct score ≥35) tests at the 14-day point.

The Welsh government web page with advice for health and social care professionals is here.