Discharge to Assess for Older People: Making Hospital Discharge Safe Without Creating New Delays

February 7, 2026

Discharge to Assess (D2A) has become a core mechanism for supporting older people to leave hospital safely without waiting for long-term decisions to be made on an acute ward. Used well, hospital discharge, step-down and admission avoidance pathways reduce deconditioning, preserve independence and prevent avoidable readmissions. Used poorly, D2A simply shifts delay elsewhere and can create distress for people and families. The strongest D2A models also recognise the realities of cognitive impairment and complexity and align with established dementia service models and care pathways, including the need for consistent routines, communication support and clear best-interests decision-making where required.

What Discharge to Assess is trying to achieve

D2A is designed to separate two things that hospitals often try to do at the same time: (1) complete clinical treatment and (2) decide long-term care needs. The intention is that older people leave hospital once they are medically stable, and assessment of longer-term needs happens in a more appropriate setting.

In practice, D2A usually means one of three routes:

Home first with short-term support (often reablement-led) and review.
Step-down bed for time-limited recovery and assessment.
Specialist placement where risks are high or needs are complex, with clear review and exit criteria.

Key risks that D2A must manage

D2A reduces hospital delay, but it does not remove risk. Providers and system partners need to actively manage:

Deconditioning and falls risk during transition and early days in the new setting.
Medication changes and continuity of MAR documentation.
Unclear responsibility between acute teams, community services and social care.
Family anxiety when decisions feel rushed or communication is inconsistent.
Capacity and best-interests decisions, especially where cognition fluctuates.

Operational example 1: “Home first” with structured 72-hour stabilisation

Context: Older people are discharged home under D2A, but early deterioration leads to ambulance call-outs and readmission within days.

Support approach: A structured 72-hour stabilisation model is introduced for higher-risk discharges.

Day-to-day delivery detail: The first visit happens within a defined window of arrival home. Staff complete a short stabilisation checklist (hydration/nutrition prompts, safe transfers, immediate equipment suitability, medication availability and understanding). A named coordinator confirms the first review date and ensures the person and family know who to contact. Where cognition is impaired, staff use simplified prompts, consistent language and visual cues, and they record any fluctuations to inform the review.

How effectiveness or change is evidenced: Evidence includes reduced 7-day readmission rates, fewer urgent call-outs, and documented completion of stabilisation checks with clear escalation outcomes (e.g., GP review arranged, therapy referral expedited, equipment replaced within 24–48 hours).

Operational example 2: Step-down bed admissions with explicit exit criteria

Context: Step-down beds become blocked because people are admitted without clear recovery goals and discharge decisions are deferred.

Support approach: Entry criteria and exit criteria are tightened and made operationally “real”.

Day-to-day delivery detail: On admission, staff agree three measurable goals (e.g., independent transfers with a frame, safe stair practice with therapy, or improved continence management with a routine). Weekly multidisciplinary reviews focus on progress and barriers, not general updates. Where progress stalls, the pathway requires a clear decision: escalate therapy input, adapt the environment, adjust the support model, or begin long-term planning. Families receive a structured update after each review, reducing misunderstanding and complaint risk.

How effectiveness or change is evidenced: Evidence includes reduced average length of stay in step-down, improved throughput, and documentation showing goal achievement rates and reasons for extension when required (with audit trails for decision-making).

Operational example 3: Dementia-aware D2A planning to prevent “failed discharges”

Context: People with dementia are discharged into unfamiliar settings or routines, triggering distress, refusal of care and rapid escalation back to hospital.

Support approach: A dementia-aware D2A planning process is embedded as standard for identified cognitive risk.

Day-to-day delivery detail: Discharge information includes a concise “what helps me” summary, key routines, communication preferences and known triggers. In step-down settings, staffing consistency is prioritised for the first week and routines are simplified. Where the person lacks capacity for key decisions, best-interests decision-making is recorded, and staff ensure family/advocates understand the rationale and the review schedule.

How effectiveness or change is evidenced: Evidence includes fewer incident reports linked to distress, reduced use of restrictive interventions, fewer complaints about communication, and clearer documentation of capacity assessments and best-interests decisions with review dates.

Governance and assurance: what “good” looks like

D2A pathways need routine assurance, not just crisis management. Strong governance typically includes:

Daily or twice-weekly system huddles for delayed cases with clear escalation routes.
Audit of discharge documentation quality (including medication reconciliation and risk notes).
Tracking of “bounce back” admissions (e.g., 7-day and 30-day readmissions) with thematic review.
Defined accountability for decisions on funding, equipment and ongoing packages.

Commissioner expectation

Commissioner expectation: Commissioners expect D2A pathways to improve flow without increasing harm. They will look for evidence of reduced delayed discharge days, stable discharge outcomes (home first where appropriate), and governance that identifies and fixes recurring causes of “failed discharge” and readmission.

Regulator / inspector expectation (CQC)

Regulator / inspector expectation (CQC): Inspectors expect safe transitions, person-centred planning and effective risk management. They will test whether people are supported to regain independence and whether decisions about capacity, consent and restrictive practice are lawful, proportionate and clearly recorded.

Making D2A work in the real world

D2A succeeds when it is treated as a structured pathway with defined responsibilities, not as a shortcut. The practical discipline is simple: clear entry and exit criteria, early stabilisation, dementia-aware planning where needed, and governance that measures outcomes and learns quickly. That is what prevents D2A from becoming a new form of delay.