When a patient with complex and ongoing health or social care needs is ready to be safely discharged from acute care, it is very important that this should happen in a timely manner. It is therefore helpful for nurses to have an understanding of the processes involved in determining the funding for healthcare services and the options available for patients once they have been discharged back into the community.

NHS Continuing Healthcare funding exists to provide a package of ongoing care that is arranged and funded solely by the NHS. It should be awarded only when an individual has been assessed as having a primary health need and it is provided to support the care that people need over an extended period of time as a result of disability, accident or illness, to address both physical and mental health needs (DH [12]). The National Framework for NHS Continuing Healthcare and NHS‐Funded Nursing Care (DH [12]) provides guidance and structure on the principles and processes of funding. To be eligible, patients must be assessed by a multidisciplinary team to determine the complexity and intensity of their need and the help they require.

The assessment process for NHS Continuing Healthcare should not be allowed to delay hospital discharge (DH [12]) but it is essential for patients’ holistic needs to be placed at the heart of the assessment process as they are frequently facing significant changes in their life and a positive experience of the assessment process is therefore crucial. There is also a legal obligation to inform patients of their right to be assessed for NHS Continuing Healthcare funding, and this can best be done by referring them to an online resource booklet on the Department of Health and Social Care's website (https://www.gov.uk/government/organisations/department‐of‐health‐and‐social‐care).

It is recognized that older inpatients have longer lengths of stay despite proactive discharge planning due to their complex needs (Mabire et al. [25]). This increases the risk of adverse events following their discharge, and initiatives to aid the transition period from hospital to home are therefore important elements in discharge preparation. Following a hospital stay, intermediate‐care teams may provide a period of intensive care and/or rehabilitation, which may take place in a care home or in the individual's own home. Intermediate care aims to prevent hospital admissions, support faster recovery from illness or injury, support timely discharge from hospital, and maximize independent living (NICE [39]). Unlike NHS Continuing Healthcare, it is likely to be limited to a maximum of 6 weeks but there are local variations in practice. Intermediate care requires a person‐centred approach, involving patients and carers in all aspects of assessment, goal setting and discharge planning.

Re‐ablement is a similar service that aims to help people regain their independence following an illness or injury. It is a community‐based service that provides assessment and interventions to people in a residential setting such as a care home or a rehabilitation unit. The aim is to optimize individuals’ wellbeing by working in partnership with them to enable confidence and independence in activities of daily living and other practical tasks (NICE [39]). Services are delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff if the service is within a care home.

Re‐ablement teams are usually made up of the following disciplines:

For patients requiring a long‐term package of care, it must be made clear to the patient and/or their family that they will be financially assessed and as a result may be charged for the service. In some local authorities, if the patient is assessed as ‘self‐funding’, social services may only then offer a signposting service to private care providers.