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Current Chapter

Current chapter – STS004

Proportion of older people (65+) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services.

Period: Hospital discharges between 01/10/2021 – 31/12/2022 with 91 day follow-up.

General description and business case

This measure collects data on the benefit to clients from reablement / rehabilitation services following a hospital episode. It captures the joint work of social services and health staff and services commissioned by joint teams as well those commissioned by social services only.

The information collected through this measure is essential for commissioning and planning and the monitoring of joint working arrangements. It is used in answering parliamentary questions and ministerial briefings. The data is used to feed into the rehabilitation/ reablement ASCOF measure 2B.

Who to include/exclude?

For clients to be included in STS004 the following criteria must apply:

  • clients are aged 65 or over at the date of discharge
  • clients would otherwise face an unnecessarily prolonged stay in acute in-patient / community hospital care or be permanently admitted to long term residential or nursing home care, or potentially use continuing NHS inpatient care.
  • the service is a short term intervention typically lasting no longer than 6 weeks, and frequently as little as 1-2 weeks or less, has a planned outcome of maximising independence and enabling clients to resume living at home.
  • clients are provided with services on the basis of either a joint multidisciplinary assessment from NHS and social care services or an assessment from social care services only, resulting in an individual support plan that involves active therapy, treatment or opportunity for recovery

Detailed guidance for data table

Reablement/rehabilitation services should not solely comprise the provision of, for example, an item of equipment, wound nursing or provision of meals on wheels or getting up / putting to bed services, nor simply restarting of service(s) already in place at the time of admission to hospital unless the service(s) were short term with an intention to maximise independence.

The measure covers both residential and non-residential short term services intended to maximise independence.


A hospital discharge is defined as an individual who has been formally admitted to hospital (rather than an individual who has attended A&E) and then discharged. The length of time between admission and discharge will vary from a few hours (for example in a clinical decision unit) to days or weeks. This table is based on the total number of discharges with a rehabilitation plan agreed jointly by the NHS and local authority or local authority only, where the objective is to see the patient return home within the reporting period, not the unique number of people who have been discharged who meet these criteria over the period.

Double counting

If an individual has had more than one discharge to rehabilitation services during the reporting period, then include each discharge. In these cases it is important to make sure that if they also have multiple reviews then the correct review is also attached to each discharge.

Collection period

The number of discharges is collected during the period 1 October to 31 December. These people are then contacted during the period 1st January to 31st March (to make it consistent with above) to see if they are still living at home. This could be done via a formal process, such as a review, or could be done informally, for example via a telephone call to the service user.

Start date

The 91 day count starts the day the person is discharged from hospital, the first day is recorded as day 1, not day 0.

Measuring time

3 months is defined as 91 days, based on calendar days, not working days.

Type of hospital

Discharges of those aged 65 and over from both acute and community hospitals should be included (discharges from psychiatric units and EMI units should be excluded). Councils and NHS partners may however want to extend the local reporting process to cover these discharges and / or instances where a joint rehabilitation plan is arranged to avoid admission to hospital.

The start date will be the day of the discharge from the last hospital in the sequence of placements in hospitals ends. Some examples are:

  • a person may be first admitted to an acute bed, then transferred to a community hospital bed, and then discharged to rehabilitation / reablement service in a care home. The start date will be the day the person is discharged to rehabilitation / reablement service in a care home
  • a person may be first admitted to an acute bed, then transferred to a community hospital bed, sent back for final checks in an acute bed and then discharged to rehabilitation / reablement service. The start date will be the day the person is discharged to rehabilitation / reablement service

Multi-disciplinary assessment

This is defined as where both the health and social care needs of the individual have been assessed. This assessment may have been done jointly by health and social care staff, social care staff only or health staff only. The key element is that both the health and social care needs of the individual have been assessed.

Living at home

This is defined as those people living in their own home in the community, including in extra care housing or a shared lives scheme setting. Those people who are in hospital (other than for a brief episode of care from which they are expected to return home) or are in a registered care home (other than for a brief period of respite care from which they are expected to return home) are not considered to be living at home.

Person not known to social services and requiring following up

These are discharges where social services have no details of the person 91 days after discharge, for example the person is not listed on the social care records or on the books to receive social care services. In these cases social services could use a variety of methods to trace these cases, as long as GDPR principles are still met.

When the person cannot be traced

For discharges where the person cannot be traced after 91 days, they should be included in the first row (Number of discharges in period to rehabilitation where the intention is for the patient to go back home) but not in the second row (Number of above discharges where person was still at home 91 days later). In other words, clients who cannot be traced should be assumed to NOT still be at home.

Last edited: 11 May 2022 9:17 am