Platform 7: Coordinating Care Across Discharge, Transfers and Teams

Scope and weight

Platform 7 is about what happens at the edges of care: admission, transfer and discharge. Those are the moments when information is lost and harm occurs, which is why the NMC gives them their own platform. If you worked in a system where discharge is a medical decision made by the doctor alone, the UK model will feel different: nurses plan, coordinate and often lead the discharge.

What is tested

• Discharge. Safe discharge planning, checklists and assessing equipment, aids and home adaptations.
• Transfers. Moving people between wards, hospitals and the community, with a clear handover.
• Medicines reconciliation. On admission, on transfer and at discharge.
• Who does what. Roles of the physiotherapist, occupational therapist, dietitian, pharmacist and social worker, and integrated care with community and district nurses.
• Social care and funding. Care Act 2014 assessments, social care funding basics, NHS Continuing Healthcare and funded nursing care.
• Planning ahead. Advance care planning and ReSPECT forms, plus palliative care coordination and rapid discharge for end of life.
• People around the patient. Carers' assessment and involvement, advocacy and navigation of services.
• Complex needs and referrals. Case management, referral pathways, urgent referrals and multi-agency safeguarding with information sharing.

Local points to anchor your answers

• Medicines reconciliation compares what the person takes, what is prescribed and what is intended at each transition, and resolves differences. It involves the pharmacist and the prescriber.
• Care Act 2014. Local authorities assess care and support needs, and have duties on safeguarding adults. Carers have a right to an assessment of their own needs. Confirm detail at source.
• ReSPECT. A shared record of a person's preferences and recommendations for emergency care and treatment, created in conversation with them. It differs from a DNACPR decision, which concerns cardiopulmonary resuscitation only. Confirm at source.
• NHS Continuing Healthcare is NHS-funded ongoing care for people with a primary health need, following an assessment. It is different from funded nursing care, which contributes to nursing costs in a care home. Confirm at source.
• Lasting power of attorney and advance decisions are legal tools under the Mental Capacity Act, not the same as a care plan preference.
• Information sharing. Share what is necessary for safe care with the people involved, respect confidentiality, and follow multi-agency safeguarding procedures where there is risk.

Three typical traps

1. Discharging before the home is ready. An option that sends a patient home because the bed is needed, before equipment, medicines and community support are in place, is wrong. Safe discharge needs those in place first.
2. Handover by memory. Transfers need a structured written and verbal handover with medicines, allergies, current problems and care preferences. Relying on the patient to explain is a weak option.
3. Mixing up documents. A ReSPECT form, an advance decision, a lasting power of attorney and a DNACPR decision do different jobs. Read what the stem asks the document to do.

How the questions are framed

Platform 7 stems begin with a person at a transition. An older man is ready for discharge but lives alone, a woman is being transferred from the emergency department to a ward with a new medicine, a family wants their relative to die at home, a carer is exhausted, or a person with a learning disability is being admitted. You are asked what to arrange, who to involve or what to check before the move goes ahead.

What the exam asks about each group

• Discharge. Confirm medicines supplied and explained, transport, equipment, follow-up and a named contact. The discharge is led by a plan that started on admission, not by bed pressure.
• Transfers. Use a structured handover, send the right documents and medicines information, and confirm receipt at the other end.
• Medicines reconciliation. Compare sources of information, resolve discrepancies and document the outcome. Do not assume the previous chart is correct.
• The team. Refer to the right professional for the problem: physiotherapist for mobility, occupational therapist for daily living and home adaptations, dietitian for nutrition, pharmacist for medicines, social worker for care needs and safeguarding.
• Funding and legal frameworks. Recognise when a Care Act assessment, an NHS Continuing Healthcare assessment or a carer's assessment is appropriate.
• End of life. Coordinate rapid discharge, community nursing, anticipatory medicines and a ReSPECT conversation so that the person's wishes are known and honoured.
• Complex needs and safeguarding. Refer urgently where needed and share information within the law and policy to protect the person.

The strongest options coordinate before the move, not after it, and involve the person and their carers in the plan.

How to revise it

1. Build a discharge checklist covering medicines, equipment, transport, follow-up, community referral, information to the patient and to the GP, and carer involvement.
2. Draw the team map: for each professional, write one line on what they contribute and when to refer.
3. Make a document table: purpose, who makes it, who can override it and when it applies.
4. Revise funding terms in a few lines: Care Act assessment, Continuing Healthcare, funded nursing care.
5. Practise end-of-life coordination, including rapid discharge, syringe pump arrangements and community nurse involvement.

Pair with Platform 1 for capacity and advance decisions and Platform 5 for team working.