• Project led by Royal Free London NHS Foundation Trust.
  • Focused on patients with dementia.
  • Aimed to give every patient with dementia a safe, dignified, timely and sustainable discharge.
  • Developed a proactive case-management model for discharging patients with dementia, with a specialist dementia occupational therapist providing a single point of contact for patients, family members and staff throughout the admission and discharge process.

The Royal Free London project team developed 'My Discharge', a proactive case-management model for discharging patients with dementia. Their aim was to give every patient with dementia a safe, dignified, timely and sustainable discharge.

A specialist dementia occupational therapist provided a single point of contact for the patient, family members and staff throughout the admission and discharge process. Key elements of the model included:

  • assessment by the specialist dementia occupational therapist within 24 hours of admission
  • early development of a discharge plan, with input from the patient, family and any carers
  • intensive daily therapy to enable the patient to cope at home
  • a quicker, supported discharge process
  • providing temporary social care cover if needed
  • psychiatric liaison review.

Who was involved

The project was led by the specialist dementia occupational therapist. The project team included the lead dementia nurse, the director of therapies, integrated care staff, a senior information analyst, a carer and member of Carers UK, a discharge co-ordinator, the clinical dementia lead and a project manager.

Outcomes

  • Average length of stay reduced by 1.9 days per person.
  • 90% of patients were discharged home.
  • 34% of patients at risk of permanent placement were discharged home with support.
  • 100% of carers agreed the personalised approach was effective.
  • Predicted cost saving of £48,708 after the first nine months.

Challenges

As the specialist dementia occupational therapist became better known on the ward, staff tended to misinterpret the referral criteria. The occupational therapist had to emphasise the importance of formal diagnosis in getting access to support services.

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