Guidance

Discharge into care homes for people who have tested positive for COVID-19: clarification note

Updated 1 April 2021

This document is based on guidance available on the date of issue. It will be updated as new guidance is published in line with the latest evidence.

Overview

This note has been created for care homes to simplify and clarify existing national guidance on discharge into care homes (published in December), particularly in relation to people who have tested positive for COVID-19.

The current requirement is for hospitals to undertake a COVID-19 PCR test on all people discharged into a care home in the 48 hours prior to discharge. All individuals who test positive should be discharged into a designated setting in the first instance to see out their isolation period. All individuals who test negative can be discharged to any care home where they should undergo 14 days of isolation as a precautionary measure. The outcome of tests should be shared with care homes prior to discharge and be included in the discharge summary information.

An exception to this process is for individuals who have previously tested positive for COVID-19 and are within 90 days of their initial illness onset or positive test date. If these individuals have already completed their 14-day isolation period from onset of symptoms or positive test result (if asymptomatic) and have no new COVID-19 symptoms or exposure, they are not considered to pose an infection risk. They therefore do not have to be re-tested and can move directly to any care home from hospital. See the discharge steps.

Key roles of care homes and hospitals

Key roles of care homes	Key roles of hospitals (in the context of interacting with care homes)
Care home manager has the absolute discretion to accept or decline a resident depending on their local context and subsequently whether to isolate that individual on admission.	Hospital discharge team must not put undue pressure on a care home to accept a resident.
Care home manager should review the discharge summary information, in conjunction with NHS clinical support to care homes if required, to satisfy themselves that due process has been followed in the clinical assessment and decision-making.	Clinical team should ensure that the time-stamped reported COVID-19 test result of the individual is included in the discharge summary information.
If any information in the discharge summary information is missing or unclear, the care home manager should seek clarification from the hospital before accepting a resident.	Clinical team should provide detailed information about the clinical assessment and decision-making process in the discharge summary information. This should state clearly whether or not the person is considered infectious and therefore whether or not it is necessary to discharge them to a designated setting. It should also include details of the individual’s previous COVID-19 symptomology, including date of onset of symptoms and severity. Information about any persisting post-viral symptoms should also be recorded.
Care home manager should ensure the care home follows its own infection prevention and control procedures.
Care home manager must ensure that the care home is operating within the margins of its organisation’s indemnity insurance.

Steps for discharge into care homes for people who have tested positive for COVID-19

Step 1: a person is determined as clinically ready for discharge

This is an individual in hospital who has received a positive PCR test for COVID-19 and is within a period of 90 days from their initial illness onset or positive test date. The individual must be clinically ready for discharge and have no underlying severe immunosuppression.

See the stepdown guidance for detailed information.

Step 2: the hospital clinical team, in conjunction with an infection specialist if required, undertake a clinical assessment against the following 3 questions

Has the individual completed their 14-day isolation period from their symptom onset or positive test result (if asymptomatic)? Isolation can only be stopped when clinical improvement criteria are met for the following:

• clinical improvement with at least some respiratory recovery
• absence of fever (less than 37.8°C) for 48 hours without the use of medication
• no underlying severe immunosuppression

Has the individual not developed any new COVID-19 symptoms? New COVID-19 symptoms include a new continuous cough, high temperature and/or loss of, or change to, the individual’s sense of smell or taste. Care home residents may not present with typical symptoms. A post-viral cough and/or loss of, or change to, normal sense of smell or taste is known to persist for several weeks in some cases.

Has the individual not had a new COVID-19 exposure? A new COVID-19 exposure is contact with a confirmed COVID-19 patient while on a ward (exposure similar to a household setting).

If the answer is ‘no’ to one or more of the questions

An individual may pose an infection risk so should be discharged to a suitable designated setting to complete their isolation period - unless they have developed new COVID-19 symptoms in which case they should be re-tested and clinically assessed in the hospital to determine next steps.

The total 14-day isolation period can be shared across the hospital and designated setting if infection prevention and control practices are not breached. If the individual has had a new COVID-19 exposure prior to discharge, then the 14-day isolation period should start from the day of the last exposure.

After the 14-day isolation period the resident must have a clinical assessment in line with the clinical improvement criteria as set out above. If the criteria are met, they can be moved to their care home without the need for further COVID-19 test or isolation.

If the answer is ‘yes’ to all questions

The resident does not require a further COVID-19 test in the 48 hours prior to discharge.

The individual may be discharged to any care home. The care home has the discretion to isolate the resident if they wish.

Care homes should continue to receive clinical support for residents following hospital discharge as outlined in the framework on NHS clinical support to care homes.