Integrating hospital and community care pathways in Bath

ContactDr Christopher Dyer, Consultant Geriatrician and Clinical Lead OPU, Royal United Hospital Bath NHS Trust
Telephone01225 821008
AddressOlder People’s Unit, Royal United Hospital Bath, Combe Park, Bath, BA1 3NG

This project aims to provide a new pathway of care for people with dementia admitted to the Royal United Hospital Bath, which puts carers and patients in the ‘driving seat’, improving discharge and reducing unnecessary admissions in future.

Too often the care for people with dementia in acute hospitals is both poor quality and expensive. Although deemed a priority there are currently few, if any, workable acute care pathways for dementia care – nor are there close links with community care pathways. A coordinated response from health and social care workers, and the voluntary sector is vital – but it is usually disjointed and not patient focused. This results in an extra week on average stay in hospital and an overall cost excess of £6.5m per Trust (National Audit Office, 2007).

The ambition of the Bath area health and social care community is to be an exemplar of best practice in dementia care: the RUH Trust board was first in the UK to state that dementia care is “core business”. We have already introduced an innovative charter mark for our wards, and the National Dementia “CQUIN” 2012 aims to improve the identification of patients with dementia in hospital, to ensure that they are assessed and referred on.

Our aim is to take these initiatives much further by ensuring it is embedded in a whole system pathway that incorporates innovations that have been shown to be effective.

By working together we will redesign, implement and evaluate an innovative pathway of care based on best practice for patients admitted to (and discharged from) hospital with possible/definite dementia. Incorporating the 5 stated aims of the challenge fund, ensuring:

  1. The right staff and skills 7 days per week: including a coordinator, a mental health liaison service based on a successful randomised trial, and rapid assessment teams
  2. Clear monitored timeframes for assessment and intervention; i.e. day 1, day 2 etc
  3. Best information and signposting for carers in hospital and then at home
  4. Optimal therapeutic environment across our wards using e.g. care bundles (standardised optimal care) and technological solutions
  5. Follow up pathways which are timely, robust, support carers and avoid readmission


  1. To make sure we have a service every day of the year that gives the right care at the right time: we currently have an early assessment team who review complex admissions – this project will place mental health specialists and coordinators into that team and ensure patients with dementia are monitored through their stay.
  2. To agree detailed care plans with carers within 24 hours of admission
  3. To make sure every ward provides excellent care using a “care bundle” to provide a safe environment, whichever ward the person goes to – this is rather like airline pilots’ “checklists”. For example making sure falls are avoided and disturbances in behaviour are minimised
  4. To use new technologies that will help patients on wards and after discharge: such as “telecare” which uses computers in the home to warn of any problems someone living alone may be having, for example, if they had wandered away from home
  5. To make sure the plan for discharge is clear and care in the community is there when it is needed: more specific resources will be made available for discharge to happen at the right time and that follow up happens properly

Anticipated outcomes

  • We will reduce unnecessary time in hospital, freeing up 8000 bed days per year
  • We will involve carers every step of the way
  • Carers will be reassured that the hospital is listening to their views
  • By planning the discharge better, and by getting better support at home, there will be 50% fewer people readmitted to hospital

Progress update

The project funded a 7 day a week innovative new service including a mental health liaison service and dementia coordinators. The role of the coordinator is to identify patients with dementia admitted to hospital and work with them, their carer and ward staff to improve the quality of their care and ensure the carer is integral to decision making. A fund to support discharge is available and, in conjunction with the mental health team, discharge decisions are more timely and support afterwards is more robust. A great deal of time and effort has gone into the care pathway with community partners who are all signed up to this project. So far, carer satisfaction with care has risen and occupied bed days have fallen but a longer period is required to assess the full impact of this service, which was only set up in April 2013.