Making a Referral (Hospital Discharge)

1. Who can make a Referral?

All referrals must be made by a health or social care professional.

2. Croydon Hospital Referrals

All Discharge to Assess (D2A) referrals should be sent by referrer via secure Cerna Millenium case management system which will then be filtered through the system via email to Ch-tr.LIFE@nhs.net.

Discharges from Inpatient Wards

Referrals by wards should only be made if:

1. The person has likely needs for care and support; and
2. There was no existing service in place prior to admission; or
3. The service that was in place before is no longer likely to be able to meet their needs.

If identified prior to discharge an individual has complex care and support needs and they are most likely unable to return to their usual place of residents a referral would need to be made by the ward staff to the Integrated Discharge Team based in the hospital. If there was an existing service prior to admission that is still able to meet the person's needs a referral to the Hospital Discharge Social Work Team is not required. Instead nursing staff on the ward should phone or email Brokerage who can arrange for the package of care to be restarted upon discharge.

Discharges from A&E and Rapid Response

Discharge to Assess (D2A) referrals should only be made by A & E, Rapid Response or any other pre-admission service if:

1. The person has likely needs for care and support; and
2. There was no existing service in place prior to admission; or
3. The service that was in place before is no longer likely to be able to meet their needs.

If there was an existing service that is still able to meet the person's needs the A & E Liaison Social Worker or Care Manager should phone or email Brokerage who can arrange for the package of care to be restarted.

Discharge to assess (D2A) has three main pathways

Pathway one

Assessment and support is provided by the health and social care community team in the patient’s own home. Once discharged, the resident is assessed within 24-48 hours from discharge by a community worker to determine their reablement potential.
Support is provided by a commissioned care provider or Croydon’s in house community reablement service. Support is provided for up to 6 weeks.

Pathway two

Assessment and support is provided by the health and social care community team in a residential intermediate assessment setting. This includes community support beds in the expected maximum assessment period is 14 days.

Pathway three

Assessment and support is provided by the health and social care community team for people who initially require 24-hour residential/ nursing care. The expected maximum assessment period is 20 days.

All Pathway three requests must be discussed in the daily Placement in Principle panel to discuss the need and ensure this pathway is the least restrictive option for individual and in their best interest.

A person may be stepped up or stepped down between the pathways as appropriate to their needs.

The support provided may involve rehabilitation (a therapy/nursing-led service) and/or reablement (a social care-led service).

3. Out of Borough Referrals

Out of Borough referrals should be made via email to Ch-tr.LIFE@nhs.net.

If an Out of Borough hospital requires additional information to plan discharge they can contact Adult Social Care support. Click here to access Croydon Adult Support procedure 'Requesting Adult Social Care Support' for further information.

Upon receipt of the referral Croydon Adult Support should email it to OOBHospitalTeam@croydon.gov.uk.