Delayed Discharge Definitions and National Reporting Requirements Advice Note v1.0 ... · 2019. 4. 17. · Information Services Division 1 Delayed Discharge Definitions and National

Information Services Division

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Delayed Discharge Definitions and

National Reporting Requirements

Advice Note v1.0

Issued April 2019

INTRODUCTION

Until recently, the majority of Health Boards have used the delayed discharge data

management system, EDISON, to record and report on delayed discharges. As this system

is being retired, most areas are now collecting data through TRAK. The ‘shadow’ period in

running both systems during the transition, highlighted some issues around data collection.

ISD, along with the Scottish Government, held a series of workshops in late 2018 to

examine the recording of delayed discharges, and this advice note is the output of these

workshops.

This document should be read alongside the Delayed Discharge Definitions Manual (DM)

and the National Reporting Requirements (NDR) which remain the official guidelines on

collecting delayed discharge data.

The DM and NDR can be found at http://isdscotland.org/Health-Topics/Health-and-Social-

Community-Care/Delayed-Discharges/Guidelines/.

http://isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/Guidelines/

http://isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/Guidelines/


Delayed Discharge Definitions and National Reporting Requirements – Advice Note v1.0 April 2019

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Table of Contents INTRODUCTION .............................................................................................................................. 1

1. DEFINITIONAL CLARIFICATION ................................................................................................. 3

1.1. What do we count as a delayed discharge? ...................................................................... 3

1.2. Why do we count delayed discharges? ............................................................................. 4

1.3. When do we count delayed discharges? ........................................................................... 5

1.4. How do we count delayed discharge? ............................................................................... 6

2. DELAY REASONS ....................................................................................................................... 7

2.1 Assessment codes - 11A/11B ............................................................................................ 7

2.2 Awaiting Dementia Bed - 24F ............................................................................................ 7

2.3 Patient Choice ................................................................................................................... 7

2.4 Capacity ............................................................................................................................. 8

2.5 Code 9 ............................................................................................................................... 8

2.6 Code 100 ........................................................................................................................... 9

2.7 Mental Health delays ......................................................................................................... 9

2.8 Learning disability delays ................................................................................................. 10

2.9 Phased discharge ............................................................................................................ 10

2.10 Appeals .......................................................................................................................... 11

2.11 Change in patient circumstances ................................................................................... 11

3. INTERMEDIATE CARE .............................................................................................................. 12

3.1. What is Intermediate Care? ............................................................................................ 12

3.2. What is Bed Based Intermediate Care? .......................................................................... 12

3.3. What is NOT Bed Based Intermediate Care? .................................................................. 12

3.4. Intermediate Care and Delayed Discharges .................................................................... 13

4. OPERATIONAL PROCESSES ................................................................................................... 14

4.1 Using TRAK to record delays ........................................................................................... 14

4.2 Out of area delays ........................................................................................................... 14

4.3 Hospital transfers within the same Health board .............................................................. 14

4.4 Hospital transfers between Health boards ........................................................................ 14

4.5 Verification of information................................................................................................. 14

4.6 RDD date changes........................................................................................................... 14

5. OUTPUTS .................................................................................................................................. 15

5.1 Published information ...................................................................................................... 15

5.2 Freedom of Information requests (FOIs) .......................................................................... 15

6. CONTACTS ............................................................................................................................... 15

6.1 ISD .................................................................................................................................. 15

6.2 Scottish Government Policy Lead .................................................................................... 15



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1. DEFINITIONAL CLARIFICATION

The vast majority of patients will be discharged from the NHS without any involvement of

other agencies, such as social care or housing. However, in some cases patients will

require additional support or services after discharge, which can lead to a delay in that

discharge. This advice is concerned with that minority of patients that do suffer a delay in

their discharge from hospital.

1.1. What do we count as a delayed discharge?

Quite simply, a delayed discharge is a hospital inpatient who is clinically ready for discharge

from inpatient hospital care and who continues to occupy a hospital bed beyond the ready

for discharge date.

A patient who has completed treatment, and is now ready to leave the care of the NHS but

cannot, will be considered as a delayed discharge. Predominately, this will be patients

waiting to return home but in some cases it will be a move to a care home or supported

housing. It may also involve a transfer to an intermediate care facility for short-term

rehabilitative care.

Inter-hospital moves to continue treatment or recovery are not delayed discharges.

It is important to ensure that who and what we count as delayed discharges meets the

public perception. In many cases, we continue to count people who have become ill again

– you cannot be a delayed discharge if you are no longer clinically ready for discharge.

We suggest a simple test be applied – if everything was in place in the community,

could the patient be discharged today? If yes, then they are almost certainly a

delayed discharge, if no then they are very unlikely to be appropriately classified as a

delayed discharge.



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1.2. Why do we count delayed discharges?

The Delayed Discharge Expert Group report states:

“The correct data is the intelligence that partners need to solve the problem”.

The accuracy of the data depends on:

a) Starting the clock at the right time

b) Ensuring the local authority of residence (and the Health Board of residence if

different to that of treatment) is known and informed

c) Knowing and recording the principal reason for delay

d) Keeping this information updated until the actual point of discharge.

There are two key purposes to the collection of delayed discharge information:

- Accurate recording of data in order to manage the timely discharge of patients

- Public reporting of the number of delayed discharges in the system and the bed

days that are associated with these.

The latter is also, of course, vital in terms of the strategic planning of service provision.

Ministers will refer to, and be held to account for, the validated national data. It therefore

needs to be consistent with other data put in the public domain, such as Board reports,

Freedom of Information enquiries and press statements. Wherever possible, such

information provision should refer to the published national data and if not possible, must be

consistent with it.



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1.3. When do we count delayed discharges?

Basically, the clock starts at the first midnight after the patient has been agreed as clinically

ready for discharge. A patient should never be entered as a delayed discharge on TRAK

before the ready for discharge date (RDD).

The ready for discharge date is determined by the consultant/GP responsible for the

inpatient medical care and where a multi-disciplinary team, in consultation with all agencies

involved, agree that the individual’s care needs can be further assessed or properly met

outside a hospital setting.

It is good practice to set an Estimated Date of Discharge date (EDD) and ideally that will be

the same as the RDD.

- However, it should not be assumed these will be the same. If the actual date of

discharge should slip, then the delay period is between the RDD and the actual date of

discharge - the EDD becomes irrelevant.

- Equally, referral to social care should, where possible, be done ahead of actual

readiness for discharge. Again, the delay period starts at the RDD and not the referral

date.

People should only be discharged when they are medically fit and when it is safe and

appropriate to do so. Premature discharge is as bad for the individual as a delay and is

likely to lead to readmission.

It is now the case in some areas, that staff can simply ‘tick’ the ready for discharge box on

TRAK and the patient will be assumed as delayed (although other local processes may be

in place). It has always been that patients classed as delayed discharges are agreed by

both health and social care and not unilaterally. This remains the case, and partnerships

must put in place a simple but effective verification process

While the responsible clinician has ultimate responsibility for the decision to discharge, the

ready for discharge decision must focus on the needs of the individual and on achieving the

best outcome for that individual. The decision must be made through a multi-disciplinary

process in consultation with all agencies involved in planning that patient’s discharge.



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1.4. How do we count delayed discharge?

Information is collected and published by NHS Board of treatment and by local authority of

residence. It is then broken down by delay reason and duration.

The reason codes are split under three broad headings – ‘health and social care reasons’

which account for assessment delays, statutory funding, place availability or care

arrangements, ‘patient/carer/family related reasons’, where there are disagreements (other

than a medical appeal), legal issues or patients exercising right of choice, or ‘code 9

reasons’ where the timely discharge is out with the control of health and/or social care

authorities.

Information is also collected under ‘code 100’ but these are not considered delayed

discharges under the definition.

Further clarity on operational aspects of the recording of delayed discharges is available in

Section 4. The following section provides further advice on specific sections of the Data

Definitions Manual.



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2. DELAY REASONS

Areas are encouraged to use the full range of delay codes, choosing the best fit based on

the main reason for the delay at any given time.

Again, for strategic planning purposes it is vital that partnerships understand the reasons for

delay. If this is place availability, then one of those reasons should be used. However, if the

delay is due to securing funding for a place, then the code should be 23C; if it is patient

choice then code 71 should be used.

ISD and the SG are happy to provide advice, but the final decision must be made locally.

2.1 Assessment codes - 11A/11B

These should only be used for the period of assessment. Once this is complete, the reason

code must be updated to reflect the main reason for delay. Not knowing or agreeing a

reason should not default to codes 11A or 11B.

2.2 Awaiting Dementia Bed - 24F

In the same way that it is important to define whether a care home placement requires

nursing or is just residential, a need for specialist dementia or EMI beds should also be

highlighted using code 24F. This will feed into the national picture of demand for these

services as well as assisting local and regional planning.

2.3 Patient Choice

Not all choice delays are 71X – this should only be used if code 9 criteria is met. If the

person is not delayed due to a code 9 choice issue, then code 71 should be used. This is

still not recorded as a ‘health and social care’ reason.



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2.4 Capacity

The use of Section 13ZA is encouraged where possible and separate advice has issued on

this (https://hscscotland.scot/couch/uploads/file/planning-discharge-from-hospital-adults-with-

incapacity-march-2019.pdf ). However, if it becomes clear the patient lacks capacity code 51X

should be applied (e.g. following the decision of the case conference). If no case

conference is held, then apply the code 51X when the rules and responsibilities have been

set out and discharging using 13ZA has been ruled out.

For 51X cases, a new RDD should be set following completion of the guardianship process

(whether this was successful or not).

2.5 Code 9

Code 9 should be used for three broad categories:

Adults with Incapacity (AWI): to be used when someone is deemed as lacking

capacity, through the guardianship process, and until the end of that process (when

guardianship has been appointed or if the application is dismissed). The code is NOT

for people lacking capacity where section 13ZA can be used. It is for delays for

specific actions under the AWI Act.

Choice: Where an interim placement is not possible or reasonable, usually for

reasons of travel distance and transport difficulties (such as off-island placements or

very rural areas). In these cases it will have been agreed by the multidisciplinary

team that hospital is a better option.

Specialist care availability: where specialist provision is required but that provision

does not exist in the area. The guidance makes clear this is about a facility not

existing within the partnership area. It is not about a lack of availability in a specialist

facility that does exist.

https://hscscotland.scot/couch/uploads/file/planning-discharge-from-hospital-adults-with-incapacity-march-2019.pdf

https://hscscotland.scot/couch/uploads/file/planning-discharge-from-hospital-adults-with-incapacity-march-2019.pdf



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2.6 Code 100

Code 100 cases are not delayed discharges under the definition. They are patients

receiving appropriate care while they go through a complex and lengthy reprovisioning

exercise, so their discharge is on-going rather than delayed. This reprovisioning process

needs to be subject to an agreed, costed plan with set timescales.

Code 100 was introduced to capture the old ‘reprovisioning/commissioning’ exclusions that

were historically not counted at all. They will likely be longer-term patients, whose needs

have changed such that there is multi-disciplinary agreement that their needs could now be

better met in the community. There is no defined period of what ‘long-term’ might be but the

code should not automatically be assumed for those in hospital for long periods. Each case

should be assessed on its own merit.

It is accepted that commissioning such care can be a lengthy process. However, they

should be coded accordingly as code 100.

Note that code 100 should not be used for people inappropriately in a rehab and

assessment unit for a lengthy period. People with learning disabilities should be recorded

against the code which best describes the circumstances relating to their situation and care

needs at any given time Where this is the case, the guidance for each scenario should be

followed and the ready for discharge date recorded appropriately.

2.7 Mental Health delays

Patients detained under the Mental Health (Care and Treatment) (Scotland) Act 2003, who

cannot be discharged from hospital, should not be classified as delayed discharges.

If however, where there is MDT agreement that it is safe and reasonable for a patient to be

transferred to a more appropriate setting, and meets the criteria for being ready for

discharge, then such patients should be classified as a delayed discharge and coded

accordingly.

The Mental Welfare Commission receives information from the quarterly code 9

narratives & code 100 data for mental health specialties.



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2.8 Learning disability delays

It is essential that all delayed patients are recorded, including those with a learning disability

who may have particularly complex needs. It is possible that these patients will need to go

through a lengthy discharge planning process, involving a range of professionals.

When it has been agreed that a patient with a learning disability no longer requires hospital

treatment, and a ready for discharge date has been set, the patient should be recorded as a

delay and coded appropriately.

Learning disability patients in learning disability services should be considered as a

discharge once:

- the admission treatment objectives have been met

- all agreed specialist assessments have been undertaken (such as speech and

language therapy, occupational therapy, forensic opinion)

- an up to date risk assessment has been provided

- it is agreed that any ongoing assessment or treatment they require could be reasonably

provided within a community setting if an appropriate community setting was available.

Patients delayed awaiting a new placement, should be declared ready for discharge,

even if a specific placement is still to be identified or commissioned/developed.

2.9 Phased discharge

A small number of patients will have an agreed planned discharge date but require a

phased discharge involving trial periods of assessment and rehabilitation at home, with an

agreed planned discharge date and discharge plan.

These patients are not yet fully ready for discharge from hospital so should not be classified

as a delayed discharge. If there is no planned discharge date, discharge plan and agreed

discharge destination then such patients should still be recorded and an appropriate code

applied.



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2.10 Appeals

A patient has the right to appeal the medical decision to discharge by seeking a second

medical opinion which should be documented.

While this appeal is carried out (which should be done as fully but speedily as possible) the

patient should remain in hospital and is not considered to be ready for discharge (and

therefore not recorded as a delayed discharge).

Once the appeal has been concluded, the patient should either remain in hospital as an in-

patient (if the appeal is upheld) or discharged without delay (if the appeal is unsuccessful).

If this immediate discharge is not possible (and the patient is delayed past the next

midnight) then the patient is classed as a delayed discharge and recorded accordingly with

the RDD being the date the appeal concluded.

2.11 Change in patient circumstances

Should a patient become unwell after being declared ready for discharge, they should not

be recorded as a delay.

In terms of the level of ‘sickness’ that would decide whether a person was no longer ready

for discharge, it was agreed that this would be that the patient is so ill they must remain in

hospital. If an individual can be discharged safely to a more appropriate setting then they

should do so.

A ‘3-day rule’ was introduced previously (section 2.7, DM) to ease the burden of removing /

adding unwell patients on EDISON. This rule allowed people not fit for discharge to retain

their original RDD if their period of illness was 3 days or less. However, the definitions

manual states this is only applicable IF local systems cannot operate real-time recording.

With the move to TRAK, most areas should no longer need to apply this rule, and patients

should be added and removed accordingly, dependent of their health needs

Patients no longer fit for discharge should be recorded with the date they became unfit for

discharge and a discharge reason of 05 (Not fit for discharge) applied (see section 6.13 in

NDR). When the person is fit to be discharged again, a new delay episode should be

created.



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3. INTERMEDIATE CARE

3.1. What is Intermediate Care?

“Maximising Recovery, Promoting Independence’’: An Intermediate Care Framework for

Scotland describes intermediate care as a continuum of integrated community services for

assessment, treatment, rehabilitation and support for older people and adults with long term

conditions at times of transition in their health and support needs. These services offer

alternatives to emergency inpatient care, support timely discharge from hospital, promote

recovery and return to independence, and prevent premature admission to long-term

residential care. http://www.gov.scot/Publications/2012/07/1181

The National Audit of Intermediate Care describes Intermediate Care as follows: Intermediate care services are provided to patients, usually older people, after leaving hospital or when they

are at risk of being sent to hospital. The services offer a link between places such as hospitals and people’s

homes, and between different areas of the health and social care system – community services, hospitals,

GPs and social care. https://www.nhsbenchmarking.nhs.uk/naic/

3.2. What is Bed Based Intermediate Care?

Intermediate Care beds provide a time-limited episode of intermediate care commissioned

and supported by Integration Authorities and provided within a care home, housing with

care, or in a discrete step-down facility within a hospital site.

Step up-beds - admitted from home for assessment and rehabilitation as an alternative

to acute hospital admission

Step-down beds - transfer from acute hospital for further period of assessment and

rehabilitation.

3.3. What is NOT Bed Based Intermediate Care?

Intermediate Care beds are not:

Transitional care that does not involve active therapy or other interventions to maximize

independence, i.e. patients who are ready for discharge and are simply waiting for

longer-term care packages to be arranged.

Longer term rehabilitation or support services.

Rehabilitation that forms part of acute hospital care. However, these patients should

not be classed as delays, as they are receiving on-going treatment.

http://www.gov.scot/Publications/2012/07/1181

https://www.nhsbenchmarking.nhs.uk/naic/



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3.4. Intermediate Care and Delayed Discharges

Intermediate care is a re-abling, rehabilitative, recovery process with a view to returning the

patient home.

What is the difference between intermediate care bed and a rehab bed?

The simple answer is probably not very much, albeit a hospital rehab ward is unlikely to

have the whole range of MDT support.

Someone receiving rehab will not be a delayed discharge wherever they are as they are still

getting treatment.

Reason code 27A should be used when the person is awaiting availability in an

intermediate care facility.

A person is not a delayed discharge if they are receiving Intermediate Care and

then wait for another service.

It has been suggested all community hospital beds are intermediate care – this is not the

case. Community hospitals will provide a range of diagnostics and treatments, many will

provide surgical procedures.

It is not the intention to reclassify beds, wards or facilities as intermediate care and then

merely move people to wait for another service.

For the purposes of delayed discharge recording, intermediate care beds are

deemed as being in the community. They cannot be in an acute hospital.

Step up-beds -admitted from home for assessment and reablement as an alternative to acute hospital admission.

Transitional care that does not involve active therapy or other interventions to maximize independence, i.e. patients who are ready for discharge and are simply waiting for longer-term care packages to be arranged.

Longer term rehabilitation or support services.

Rehabilitation that forms part of acute hospital care. However, these patients

are not classed as delays, as they are receiving on-going treatment.

Step-down beds - transfer from acute hospital for further period of assessment and reablement.



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4. OPERATIONAL PROCESSES

4.1 Using TRAK to record delays

Operational verification of patients delayed is essential.

Oversight of use by ward staff indicating a person is ready for discharge – this is a multi

disciplinary decision.

Data ‘sense’ check prior to submission of nationally required information is essential

Delayed Discharge Date / Delayed Discharge Reason refers to the date/reason the

delay episode ended, and are distinct from those used on TRAK.

4.2 Out of area delays

The Health & Social Care Partnership of residence MUST be notified of a delayed

patient. This does not happen automatically via TRAK.

4.3 Hospital transfers within the same Health board

If a patient is transferred to another hospital during their delay, the original admission

date should be submitted.

Note that inter-hospital transfers should not be classified as delayed discharges.

4.4 Hospital transfers between Health boards

If a delayed discharge patient is transferred to a hospital in another health board, the

original delay episode should have a discharge reason and date added.

The receiving health board should record a new delay episode, with the date of

admission to their care, and a revised ready for discharge date, according to their

assessment of the patient.

This will avoid the receiving health board being held accountable for delayed bed days

occurring elsewhere.

4.5 Verification of information

All data submitted to ISD on a monthly basis should be verified prior to submission.

Details of the data quality checks undertaken by ISD are available: https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-

Discharges/Guidelines/docs/Delayed-Discharge-Data-Quality-Checks-v1.0-April-2019.pdf

4.6 RDD date changes

The ready for discharge date should only be reset in the following scenarios:

Patient is unfit for discharge, and fit again at a later date

Guardianship process completed (51X) or no longer required (eg use of Section 13ZA).

! For the national monthly data submission ISD would expect to see 2 rows of data

per patient in these cases.

https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/Guidelines/docs/Delayed-Discharge-Data-Quality-Checks-v1.0-April-2019.pdf

https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/Guidelines/docs/Delayed-Discharge-Data-Quality-Checks-v1.0-April-2019.pdf



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5. OUTPUTS

5.1 Published information

ISD published monthly and annual delayed discharge information which can be found:

http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-

Discharges/

5.2 Freedom of Information requests (FOIs)

Media reaction to FOI responses, highlight the importance of accurate information,

as Ministers will be approached for political justification.

Refer to published data where possible.

ISD / SG can offer general advice, but not respond on behalf of Boards/Partnerships

6. CONTACTS

6.1 ISD

For queries regarding the national data set and definitions, please contact:

Lisa Reedie

Principal Information Analyst

NHS National Services Scotland

Information Services Division (ISD)

Phone: 0131 275 6117

Email: [email protected]

6.2 Scottish Government Policy Lead

For queries regarding policy, please contact:

Brian Slater

Delayed Discharge Policy Manager

Scottish Government

Phone: 0131 244 3635

Email: [email protected]

http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/

http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-Discharges/

mailto:[email protected]

mailto:[email protected]

Documents

Delayed Discharge Definitions and National Reporting Requirements Advice Note v1.0 ... · 2019. 4. 17. · Information Services Division 1 Delayed Discharge Definitions and National