2015 NICE指南（NG.27）：成人住院患者在社区以及家庭护理之间转变的社会保健需求

This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people's experience of admission to, and discharge from, hospital by better coordination of health and social care services.

The guideline includes recommendations on:

·         person-centred care and communication and information sharing

·         before admission to hospital including developing a care plan and explaining what type of care the person might receive

·         admission to hospital including the establishment of a hospital-based multi-disciplinary team

·         during hospital stay including recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge

·         discharge from hospital including the role of the discharge coordinator

·         supporting infrastructure

·         training and development for people involved in the hospital discharge process.