BNSSG Healthier Together

Discharge to Assess

We know people recover best at home after a stay in hospital.

Staying in hospital any longer than necessary reduces a person’s independence, leads to muscle loss, and increases the risk of healthcare associated infections, pressure sores and becoming incontinent.

People remain more active and do more for themselves in familiar surroundings. In addition, people enjoy better sleep and better mood among friends, family and their usual home comforts.

That’s why Bristol, North Somerset and South Gloucestershire ICS always thinks ‘Home First’ and teams across the system do all they can to enable people to recover in the place they call home, supported with any necessary monitoring and rehabilitation.

For those people who no longer need hospital care, but may need further support while they recover, it is better to assess their rehabilitation and other needs outside of hospital, ideally in their home environment.

Rehabilitation at home empowers people to do more for themselves and to be actively involved in their recovery, so their actual needs can be better assessed.

Discharge to Assess is our way of getting people home or to a community unit when they are medically ready, so their needs can be assessed and they can be supported to recover.


There are lots of different teams and organisations involved in the Discharge to Assess pathways. Find out more about colleagues across the system who, like you, are working to support people to get back to the place they call home.

Who’s who and what do they do?


This guide for staff explains  the D2A pathways in detail. There’s also a summary guide which sums it up for a quick look.


Listen to our podcast series, which explains aspects of D2A in greater detail. The series is hosted by Anne Cooper, former Chief Nurse at NHS Digital.

What makes a good Transfer of Care (Toc) Doc?

This episode focuses on the Transfer of Care Document and its important role in getting people discharged from hospital on the right pathway. This decision making is done by the Community Transfer of Care Hub, known locally as CTOC. Guests include Kinlay Burns and Emily Richards, who are both experienced case managers working in Sirona care & health’s CTOC to manage the discharge of service users. Please note, there is an incorrect number cited at the end of the podcast by Emily. The actual number for the Bristol CToCH is: 07977 943 218.