The evidence suggests that a structured discharge plan tailored to the individual is best practice (McNeil [26]). Guidance from the National Institute for Health and Care Excellence (NICE) ([37]) emphasizes this person‐centred approach by highlighting the importance of information sharing between the patient, their family or carers, and all health and social care practitioners involved to ensure a safe and co‐ordinated transition. Patients need to be considered as equal partners in the process where the foundations for decisions are based on what is important to the individual and their needs and preferences (Weiss et al. [53]). This approach also promotes the highest possible level of independence for the patient, their partner and their family by encouraging appropriate self‐care activities and participation in the discharge planning process.

The roles of both family members and informal caregivers are crucial in supporting the discharge planning process, as Mabire et al. ([25]) indicate. Therefore, providing the patient and their family with information, knowledge and confidence in their care before they leave hospital is an essential component of discharge preparation. Evidence suggests, however, that during a patient's hospitalization, family and carers often receive limited communication and education regarding the care of their loved ones after discharge (Cacchione [5]). This can leave patients unprepared for the transition home; they can feel a sense of abandonment (Wallace et al. [51]) and are rendered more likely to require a readmission. It is therefore vital that nurses and other members of the multidisciplinary team discuss with the patient and their family how they will manage their condition after their discharge and offer appropriate teaching and support to enable self‐care. The use of patient information sheets to aid this process has been found to be effective and may help both patients and their families feel more prepared for discharge from hospital (New et al. [29]).

Assessment of patients’ individual needs for discharge is of particular importance when considering transfer from an acute care setting. The NICE ([37]) guidance indicates that practitioners should work together ‘to identify factors that could prevent a safe, timely transfer of care from hospital’ (p.12). Assessing risk and the prompt sharing of pertinent concerns regarding a patient's physical, psychological or cognitive ability enables earlier intervention from the multidisciplinary team, thereby helping to ensure patient safety and wellbeing (Lees‐Deutsch et al. [23]). Staff should have a clear understanding of their roles and responsibilities and work collaboratively (Elliott and DeAngelis [13]). The NICE ([37]) guidance recommends that the multidisciplinary team should be identified as soon as a person is admitted and that there should be regular contact with the community team to provide co‐ordinated and planned ongoing support.

To achieve the best continuity of care after discharge, there needs to be effective communication across all disciplines, and with the patient and their family (New et al. [29], Mabire et al. [25]). This ensures that the patient's wishes are heard and acted upon appropriately (Winfield and Burns [54]).

Co‐ordination of discharge care planning should be led by a ‘single health or social care practitioner’ (NICE [37], p.10); this nominated person is often a key worker or discharge co‐ordinator. A key worker is a single named person who has agreed with the patient to be their first point of contact for support, information and care planning. Discharge co‐ordinators are, in general, health or social care professionals who have both hospital and community experience. Their role is to advise, help with planning and assist the co‐ordination of the differing care providers that the patient may need when they leave hospital, particularly when their nursing and care needs are complex (Lees [18]).