This project will support people with dementia to be discharged back to their own home as soon as possible following an attendance at A&E or an admission to an acute hospital in West Kent.

People with dementia are likely to stay in an acute hospital three times longer than other people following an admission. This project aims to provide enhanced support to people with dementia to discharge them home once they are medically fit to reduce confusion and disorientation and stress and pressure for their carers.

By having domiciliary intensive support resources available to support people in their own homes this will enable the person with dementia to be discharged sooner from an acute hospital.  The Dementia Discharge Support Service offers intensive periods of support to people with a known or suspected diagnosis in order to facilitate timely discharge and give them the opportunity to return to their homes in the community.  We want to further develop this service to ensure timely discharge to prevent delayed transfers of care and reduce the average length of stay.  The service would be for a maximum of 24 hours a day and for up to 6 weeks post discharge. This will delay admission to long term residential care as individuals will be receiving the appropriate levels of care and support to enable them to remain in their own homes.

Where this is not possible for people to be discharged back to their own home they will be discharged to a short term step down facility to maximize their recovery and allow time for full and proper assessment, maximizing the use of community hospital and local care home step down beds.

In addition if people with dementia remain in an acute setting they become more confused and disorientated and their needs may be assessed to such an extent they require a care home placement rather than being suitable to return to their own home.  Through earlier discharge the premature admission to a care home may be delayed and the person will retain their independence, choice and control.

Objectives

1. To enable people with dementia to return to their home following an attendance at AE and/or an acute admission and therefore promote independence, regain as much control over their lives as possible and re-establish their confidence in living in their own home.
2. To improve hospital discharge support for people with dementia, their families and carers and therefore reducing increased confusion for people with dementia and stress for carers
3. To reduce the delayed transfers of care for people with dementia and ensure maximum use of acute hospital resources
4. To reduce the number of long term care placements made following an acute admission for people with dementia
5. To reduce the length of stay and number of excess bed days for people with dementia who are admitted to an inpatient bed
6. To support the cultural change of Health and Social professionals so that they reduce risk adverse practices when discharging people with dementia from acute inpatient beds of

Anticipated outcomes

1. To enable people with dementia to enjoy a good quality of life and live safely in their own homes.
2. To promote independence of people with dementia and their carers.
3. To enable carers and other family members to continue in their caring role whilst reacting to certain unplanned events
4. To enable the person needing care to have minimal disruption to their daily activities through the provision of one to one care in their own home.
5. To enable individuals to remain living in their own homes with appropriate support, including night sitting where necessary
6. To reduce confusion and stress for people with dementia caused by staying in acute hospitals which would in turn result in additional stress and pressure for their carers
7. To keep individuals functioning for as long as possible in their own environment and reduce mortality.
8. To provide people with dementia support to enable them to return home following a period of acute inpatient hospital care.
9. To reduce the length of stay for those people with dementia who are admitted to an inpatient bed.
10. To minimise the need for long term care for people with dementia by enabling them to regain as much control over their lives as possible and by re-establishing their confidence in living in their own home.
11. Ensure that care home admissions are appropriate and not a substitute for lack of any community resource

Progress update

This is currently at one of the two hospital sites in West Kent. The service could be extended to the other hospital site, and even to community hospitals.