Use case: hospital discharge into social care

An older person leaves hospital after a fall. The conformant model lets the ward, the discharge team, and the community social care provider describe one continuing episode in one vocabulary.

Discharge is the classic continuity failure: clinical information stops at the hospital door and social care starts again from scratch. With the conformant model, the hand-over is a sequence of well-defined concepts rather than a leap of faith.

Figure 1. From inpatient episode to support at home
From inpatient episode to support at homeFlow from an inpatient episode of care through a joint care needs assessment, a discharge report and integrated care plan, and a social care activity mandate, to social care activities in the person's environment, with care evaluation feeding back and a single thread of care running beneath. HOSPITAL SHARED RECORD & PLAN COMMUNITY Inpatient episode of care hospital care team Care needs assessment clinical + social personnel Discharge report + integrated care plan clinical, mental & social needs addressed together Social care activity mandate community provider authorised Social care activities support in the person's social environment care evaluation feeds an updated assessment One subject of care — one unbroken thread of care episode of care · health thread · shared health record concepts throughout Every hand-over uses concepts both sectors share, so nothing is retyped, re-asked, or lost in translation.

Concepts at work

  • The hospital stay is an episode of care within the person's continuing health thread.
  • A care needs assessment — the handover target for the health state understood through the hospital's investigations — is carried out jointly: the model expects clinical and social care personnel to contribute to the same assessment, not to run two disconnected ones.
  • The results flow into a discharge report and an integrated care plan addressing physical, mental, and social needs together.
  • A social care activity mandate makes the community provider's authority and responsibility explicit — the hand-over is accountable, not hopeful.
  • Social care activities then support the person to live in their social environment, with care evaluation of those activities informing an updated care needs assessment as circumstances change.

Because every step uses concepts both sectors share, nothing has to be retyped, re-asked, or reinterpreted at the boundary — and the person tells their story once.