Discharge
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Last reviewed: 27/08/2025
Discharge
Discharge
The role of the nurse in the process of discharge includes both a coordinating and educative activity. The registered nurse teaches self-care, organises services and arranges medicines and follow up interventions.
Research evidence shows that periods of transition can be a difficult time for people and there is an increased need for joined up care where the person and their family understand what can be expected, and what to do if further help is needed.
The principles which apply when someone joins a residential home can be used to support the resident leaving the care home.
The needs of the resident
A named nurse is responsible for coordinating discharge home. The nurse will be the central point of contact for health and social care practitioners, the person and their family during discharge planning. He or she is responsible for liaising with family members and the multidisciplinary team, providing information, care planning and support such as:
- printed information
- face to face meetings
- phone calls
- hands on training, including practical support and advice
- the need for assessments for eligibility for health and social care funding
- details of community nursing and voluntary service.
The home will provide details of who to contact about medication and equipment problems that occur after the return home. The nurse should give a plan of care to the person and all those involved in their ongoing care and support, including families and carers (if the person agrees).
Seema returns home
Seema returned home to live with her family with ongoing care from community nursing and the community mental health team as well as visits by formal carers to help with her personal care.
Sue was responsible for Seema's transfer home and worked closely with her family and community teams to meet Seema's needs and ensure a smooth transition. Sue's experience made her consider if Seema was entitled to further funding and started the assessment process. This assessment was done in conjunction with Seema's family, GP and the community teams. Sue also referred Seema's family to the local authority for a new carer's assessment.
The RCN has a number of resources to help staff identify and support people's mental health needs.
Further resources
The needs of family and friends
The nurse's role will be to support family members in re-establishing and maintaining the caring role. The nurse will provide information and address education needs with regard to changes in treatment and medication, and will support family members as they learn about new equipment. The nurse will discuss how to access support, such as ensuring they are aware of carers groups and community support.
Following Seema's return home, she settled back family life well, but her family found that whist Seema enjoyed the noisy young family members there were occasions when this seemed to overwhelm her and Seema retreated into herself. Her family spoke with their community mental health nurse, who suggested to Seema that she might enjoy some time with people of her own age.
Many care homes are offering day or sessional opportunities, "taster events" and overnight stays. The video below describes how one care home worked with the RCN on a dementia care development programme.
Further resources
The needs of nursing colleagues
Discharging a resident is an increasingly common scenario now that care homes provide a wide range of services including respite and rehabilitative care. We know that discharge care needs to be seamless. In addition to involving the resident in their care, a meticulous handover to community teams and the person's family is necessary. In this section we will focus on medicines optimisation.
Seema - Medicines management
When Seema returned home she was taking different medicines to the ones she was admitted to Red Cedars. Her dosage of medication had been changed a number of times and she was now on a maintenance dose which would need to be reviewed by the CMHT.
Seema found it hard to remember her dose of new medication but her previous regular medication she remember the time for administration and the reasons why she was taking them.
Good medicines management, or optimisation of medicines, is an integral part of most nursing and midwifery practice and includes the administration of medicines, prescribing and supporting people to take their medicines correctly.
The term medicines optimisation is now more generally used to encompass a more people centred approach to the use of medicine as part of a person's care. The Royal Pharmaceutical Society (RPS) good practice states that medicines optimisation is vital to health care and that the evidence base clearly demonstrates that health care professionals and patients need to work together to improve the quality of medicines use.
There is good evidence that medicines management supports better and more cost effective care.
Danilo - advancing career
Seema returned to Red Cedars for one afternoon every other week to attend their memory café; whilst there she met with Danilo again and discussed some concerns she was having with her medication.
Danilo liaised with the GP surgery and mental health team and became increasingly interested in broadening his scope of practice to address both prescribing and physical assessment.
Danillo was keen to undertake an advanced programme and sought support and advice through the RCN credentialing programme to ensure any further study meets the requirements of the programme.
The video below gives an example of a colleague's career pathway and like him, advanced practice would be a further development Danilo might wish to undertake.
Further resources
Practice interventions (resources)
Below you will find some further links to resources.
Resource lead
Contact details for the resource lead:
