High Impact Change Area F: Optimising the discharge process – case studies

Plan

The Admiral Nurse Transitions of Care service aims to support people with dementia, their families/carers, and professionals to improve the quality of care by adopting a person-centred approach from admission through to discharge and beyond. The Admiral Nurses work across the whole system including people's homes, care home providers and within the acute sector to implement best practice in dementia care and improve the quality of transitional care.

Implementation

The Western Devon Admiral Nurse Transitions of Care service is delivered in conjunction with Dementia UK. This service consists of two band 7 nurses and is hosted by Livewell Southwest, working closely with University Hospitals Plymouth NHS Trust. Western Devon encompasses the localities of Plymouth, South Hams and West Devon.

The service focuses on case management for people living with dementia and their families, improving the quality of their care and addressing their needs from admission through to discharge. The service also includes 6-week intensive post-discharge support in care homes and home settings.

When the patient is in hospital, a comprehensive holistic assessment of needs is conducted, along with promoting a culture of positive risk management amongst staff and role modelling of biopsychosocial interventions that impact length of stay.

The aim is to ensure a ‘home first’ approach, whilst working with other professionals to share appropriate information across care boundaries thus ensuring personalised care.

The six-week intensive post discharge support encompasses working collaboratively with care providers and the family to improve coping skills and avoid placement breakdown and/ or carer breakdown, thus reducing readmission to hospital. Admiral Nurses act as a single point of contact to readily provide advice and support from the hospital through to the discharge setting.

Outcome

Increase in home first, supporting people to be discharged to the most appropriate place of care and championing the least restrictive option. Only 9 per cent of patients have been discharged to a nursing home from an audit of 95 cases, hence reducing costs to the system. 30 per cent of patients were able to be discharged home. In Plymouth, the greatest proportion have been discharged on Pathway 2 (D2A).

• Pathway deflections have successfully shown savings and improved outcomes, for example, eight patients were deflected from pathway 3 to pathway 1 back home.
• Reduced avoidable readmissions to hospital: There have been no avoidable readmissions from an audit of 320 people living with dementia supported by the service
• Reduced length of stay in the acute hospital, with one-third of referrals to the Plymouth Admiral Nurse discharged within 48 hours of referral
• Reduced 1-2-1 support usage
• Reduced usage of anti-psychotic medications
• Involving informal carers in discharge planning