Discharge teams can complete the referral passport form for their patients, and connect with available supported living vacancies across the country.
Delayed discharges cause problems both for patients, who generally want to be out of hospital and regaining their independence, and for the NHS. Delayed discharges cost the NHS around £2.7 billion in 2025-26 – so, here at FYR, we want to do our part to help people leave hospital quickly and safely.
To access the supported living referral passport, contact the FYR team.
How does the FYR referral passport work?
Using the referral passport is simple.
- 1. The patient’s healthcare team decides they no longer need to stay in hospital, but are not able to be discharged to their own home.
- 2. The discharge team completes the FYR referral passport.
- 3. FYR will shortlist a selection of appropriate supported living accommodation with availability.
- 4. The discharge team can contact providers via an easy email link, or call them directly, and share the referral passport form with them – this ensures that hospital teams are only contacting available accommodation, and care services have the information they need.
Will any personal data be shared?
The FYR referral passport lets teams communicate about prospective service users without sharing identifying personal information.
Hospital discharge teams will not be asked to share a patient’s name, NHS number, address, or date of birth.
Instead, the form simply asks for information that can help decide placement criteria, including:
- Age and gender
- Primary need category – for example, physical disability, learning disability, dementia, or mental health concerns
- Any other health conditions, such as diabetes or epilepsy
- Details about the level of support required and personal care needs, such as medication management, continence care, or meal preparation
- Details about mobility and access requirements
- Details about whether the patient poses a risk to themselves or others
- Details about how the patient will pay for supported living
- Information about preferred locations and types of property
If a patient has risk assessments, care plans, OT assessments, or other documents available, discharge teams can share these with shortlisted providers later in the process.
Why do hospital discharges take so long?
After an illness or injury, many people need additional support, so they can’t immediately be discharged from hospital to their own home. Instead, their hospital discharge care plan may say that they need to move to a supported living scheme or care home, or get help from a home care agency.
Some reasons that a hospital discharge may be delayed include:
- The patient has mobility issues, and would struggle to move around their home.
- The patient needs specialty equipment, such as a hospital bed.
- The patient needs support with medication.
- The patient needs support with wound management.
- The patient needs support with personal care, such as washing and dressing.
- The patient would not be able to prepare meals or feed themselves.
- The patient would not be safe at home due to memory issues or lack of understanding – for example, they may leave taps running or a stove unattended.
For some patients, these conditions are temporary. They may need a short-term stay in a residential setting, or a short-term home care package, until they recover. Other people may need a long-term care home or supported living placement.
If you have more questions about the hospital discharge process, check out the NHS guide to being discharged from hospital.
However, it’s not always easy to discharge a patient to a residential placement or home care service.
First, the discharge team needs to find suitable accommodation with availability – but this can be difficult.
Discharge co-ordinators often need to contact multiple services individually about clients, which can be time-consuming. They will need to explain the patient’s condition and needs in every email or phone call – and they may still find that the service doesn’t have any availability.
This is where FYR’s referral passport can help. It shortlists accommodation that’s both suitable and available for a patient, saving the discharge team significant time – and allowing the individual to leave hospital sooner.
How will the referral passport help me?
Whether you’re part of the hospital team, a patient, or run a care service, the referral passport can help you. Let’s look at this in more detail.
I’m a hospital discharge co-ordinator
The referral passport can help hospital discharge teams speed up the discharge process.
Discharge teams currently have to dedicate a lot of their time to finding suitable accommodation for patients who are ready to leave hospital. However, with no national database of available residential placements, searching for accommodation usually involves many individual phone calls, voicemails, and emails.
The referral passport aims to change that. Instead of spending significant time calling and emailing care services, with no guarantee that they have availability, discharge teams can simply complete the referral passport form and find out about suitable supported living vacancies.
It will save your team time, and help you discharge patients to new social care settings more quickly.
I’m currently in hospital, or waiting for a loved one to be discharged
As a patient waiting for discharge, the referral passport can help you leave hospital sooner.
Your healthcare team may feel that you’re ready to leave hospital, but you might not be able to return to your own home yet. Perhaps you still need help with medication or personal care, or your home isn’t suitable for someone with mobility issues.
If your hospital discharge team is using the referral passport, you don’t need to wait for them to call multiple care services to find suitable accommodation for you. Instead, they’ll simply fill in the referral passport, and get the details of appropriate providers with availability.
Care services can then work with the hospital team to get you into the right accommodation for you as quickly as possible.
Don’t worry, though – the referral passport doesn’t share personally identifying details with prospective care providers.
It asks for information about your age, gender, support needs, and other requirements – but care services won’t have access to your name, date of birth, address, or other personal details.
I run a care service
If you run a supported living scheme, the referral passport can help to connect you to prospective clients.
Supported living providers with vacancies can list their availability and specialities on FYR. When discharge teams complete the referral passport, FYR will create a shortlist of appropriate care services with availability.
The discharge team will have completed the referral form, which includes details about the individual’s care needs, risk level, mobility requirements, and funding. This information will help you decide whether your service is suitable.
The referral passport can also help to link you with potential clients from all over the country. If your accommodation is suitable for a patient, discharge teams from across the country will see your service’s details.
Find Your Room is designed to support both care seekers and care providers.
As a care provider, you can list a care or nursing home for just £24 per month. And, starting soon, if you’re a registered charity or run a supported living scheme, you can list your properties for free. Find out more about how to sign up as a provider on Find Your Room.
How do I learn more about the referral passport and Find Your Room?
Do you want to find out how the referral passport can support your care service or discharge team? Contact the team at Find Your Room today – we’d be delighted to help you!
