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Target audience: Integrated Care Systems, intermediate care team leaders and intermediate care commissioners, community NHS and social care providers, and multidisciplinary teams in Care Transfer Hubs (including rehabilitation services, for example occupational therapists and physiotherapists).
Setting out the challenge
Having appropriate community provision for people with dementia is imperative, given that over 50 per cent of hospitalised older people with dementia are at an increased risk of hospital readmission within 30 days of their discharge, of which 20 to 40 per cent may be preventable (BMC Geriatrics, 2024). People with dementia and delirium typically experience higher levels of deconditioning, distress or disorientation as a result of being in hospital, especially if they have experienced multiple ward moves. It’s therefore the case that when they are assessed for discharge individuals will present with a higher level of (short-term) needs, often leading to inappropriate long-term placement.
A lack of knowledge of what can be provided in the community to support the person at home (for both admission avoidance and discharge) can also lead to unnecessary long-term placements. Discharge destinations for people with dementia and delirium can be limited (i.e. not accessible or not attuned to their needs) which unnecessarily drives them towards a permanent bed-based placement.
It is important that the person has an opportunity to be assessed in their usual place of residence or in a temporary placement (where required), before a long-term decision is made about the level of care that they need. Where they are to be assessed at home or in a temporary placement, it is important that suitable care is provided in these settings that promotes optimal recovery, so that an accurate assessment of the person’s capabilities and needs can be made, that reflects their true potential.
Voices from stakeholders
There’s a false perception that people can't improve, but it’s often about waiting for the right time to assess them."
Specialist input is required for this cohort in intermediate care – speech and language, diet and dementia itself."
It's like pushing against closed doors to get access to any step-down beds. Why should it be a fight given the number of people who have dementia and need to leave the hospital. It’s like we’ve designed the system to keep them stuck there.’
Outcomes
G.1 Intermediate care environments that are suitable and attuned to needs of people with dementia, and reduce the risk of (re) admissions
G.1.1 Deliver home-based intermediate care (i.e. Pathway 1) that provides a seamless transition from the acute hospital to home (and reduces the need for admission), with the appropriate wrap around support.
This includes:
- developing a practical partnership with representatives from housing, homecare, and domiciliary care to enable the provision of an integrated offering within the local area
- ensuring that there is sufficient community capacity or services to deliver the care required Including virtual wards, community mental health teams, primary care frailty multidisciplinary teams (requiring a review of demand and capacity)
- optimising use of home-based, rather than bed-based care as a system-wide culture to promote Home First where possible. This means more reablement options, where the person is close to existing services (for example, GP, Pharmacy) that know them and can support them best
- active risk management across organisations, taking a multidisciplinary approach, to reach a reasonable balance between safety at all times and independence (for example, any further needs at home as assessed by occupational therapist or physiotherapist to enable the patient to return home safely). This includes considering enabling factors to deliver care at home such as: equipment (for example, Molift, frame); virtual remote monitoring (for example, vital stats); assistive technology, (for example, falls alarms, sleep mats, medication aids); and point of care testing (for example, blood and urine testing). This also requires careful consideration of any implications on the care partner, and recognise where additional responsibilities could contribute to care partner crisis
- ensuring good communication back to primary care, who should be in receipt of all decisions and comprehensive notes, to better manage support requirements when they are ‘discharged’ from the service
- identifying the local Independent Mental Capacity Advocate (IMCA) who is trained to represent adults who lack capacity to make decisions for themselves. They can be called upon when a person lacking capacity is ‘unbefriended’, which means they have no one to represent their views during the best interest process.
G.1.2 Deliver bed-based intermediate care (i.e. Pathway 2) that provides an environment and team that is able to offer the right support to deliver better outcomes.
This requires consideration of:
- the environment, which should be dementia-attuned (described under ‘improving the hospital experience) to maximise positive outcomes
- the skill mix of the team, and their ability to offer person-centered care, that will best support the person with dementia (or DSD) and respond to their needs.
- Whether this provision is possible within existing bed-based facilities or whether there should be a more bespoke offering (for example, a dedicated dementia unit where the environment is designed to be dementia-attuned) in line with local commissioning budgets
- the offer for rehabilitation and reablement opportunities as standard, where people are regularly reviewed for their ability to achieve their personal goals and return home. This should include the provision of meaningful activity that can provide value and quality to a person’s life
- the ability to welcome care partners, who can often support in delivery of better patient outcomes.
G.1.3 If a (re) admission does occur, where clinically appropriate, the person should be returned back to their usual place of residence as a priority.
This requires a nuanced view of:
- The detrimental effect of an avoidable admission for the person, versus the ability to transfer them back into a familiar place where they can have optimal recovery.
- Keeping open packages of care for that are already in place, to enable people to return to their usual place of residence, which may be outside of normal thresholds to close intermediate care packages. This recognises the importance of a familiar face and continuity of care, and the ability for a more expedited discharge.
- Learning from admissions, to review whether any of these were avoidable (e.g. a UTI driven by dehydration), and where they were put in place changes to prevent their reoccurrence.
G.2 Intermediate care providers to have staff with the skills and knowledge to respond to the needs of people with dementia and delirium
G.2.1 Agree a minimum training requirement (basic skills) for any staff involved in the delivery of intermediate care services for people with dementia and delirium, and the ability to draw on more specialised skills where required.
This could include:
- a person/ goal centred approach with reablement at the heart
- a clear articulation of roles and responsibilities, so that staff members know what needs to be managed by them, and where support is available (e.g. for care homes through the enhanced health in care homes framework) or where more specialised skillsets are required (e.g. identifying a skilled dementia practitioner available in the community)
- access to materials, resources and information that can best support them, , the people they care for, and their care partners. This should enable the person to leave bedded care with confidence – for example, contact details for 24/7 medical and support services
- awareness of escalation measures (i.e. what to do in crisis), and the importance of acting in line with a person’s wishes, active involvement of the care partner, and any documented preferences as part of their ‘this is me’ document or care plan. This includes information and training of how to best manage distress, in order to keep the person safely at home
- a proactive approach to prevent delirium where possible, and ability to recognise if a person is presenting with delirium (i.e. the signs of change). Depending on their role, they should either be able to draw on the relevant professional to support the person or be able to provide the support themselves, in line with the person’s care plan.