‘My Discharge’ was launched at the Royal Free London NHS Foundation Trust in April 2013. Part of the Health Foundation’s 2012 Shine programme, the project aims to improve patient and carer experiences by ensuring that people with dementia stay in hospital for less time than those who do not have the condition.

David and Sally’s story

It was the third time David Hill* had been in hospital for the same reason in 12 months. He arrived at the Royal Free in May 2013 after numerous falls at home, and with incontinence. His wife Sally* cared for David on her own and was very concerned that despite the problems they were experiencing, he should remain at home with her.

Once in hospital, David was diagnosed with Alzheimer’s. He was referred to the My Discharge project where staff worked with the couple to get David home as quickly as possible, and with the most appropriate package of support.

Becky Lambert, the dementia specialist occupational therapist who runs My Discharge, assesses patients for discharge within 24 hours of referral and builds up a picture of what they need to be discharged home safely and remain there. She also provides intense therapy and acts as a single point of contact for patients and carers. While David was in hospital, Becky advised Sally on how to cope with caring for her husband.

When patients are discharged, they leave with a discharge letter and emergency phone numbers, and can be accompanied home with food and clothes, if needed. David was discharged after 11 days and, thanks to Becky’s liaison with social care colleagues, now has carer visits twice a day and a sensor near his bed to manage night time wandering.

Becky also organised for a Royal Voluntary Service (RVS) volunteer to regularly visit the couple. ‘Without our involvement, it is likely that David would have been readmitted to hospital or discharged to a nursing home which may have resulted in his quick deterioration,’ says Becky. ‘With our support, David remains in his place of choice and Sally is being supported to continue caring for him.’

Using patient and carer stories to improve care

My Discharge aims to address key issues identified in the 2009 National Dementia Strategy around the need to improve coordination between hospitals and care providers when patients with dementia are discharged. The 2010 Alzheimer’s Society report, Counting the Cost, further identified that patients in hospital with dementia stay around 5-7 days longer than those without dementia.

Because the degree to which patients with dementia can understand and engage varies so greatly, the My Discharge team have also focused on collecting carer stories to help inform their work reducing readmissions to hospital. A questionnaire one month after discharge gathers information from carers.

The team, headed up by Integrated Care Lead, Fran Gertler, also get feedback from video interviews with staff. ‘We want to make the My Discharge project a substantive service and are using the triangulated evaluation to build a business case to support this’, says Fran.

Case management approach

In only five months since its launch, the case is already strong. Survey feedback shows that 91% of carers agree or strongly agree that the patient they care for had a positive experience with My Discharge.

Fran and Becky think that key aspects of the improved coordination are the close partnership working they’ve established with organisations like RVS, community and mental health services, social services, and securing senior colleague support within the Trust.

A strong case management approach is also key to the project’s success. ‘Carers often say that getting a phone call from Becky the day after the patient is discharged, and regular follow up after that, makes a big difference’, says Fran.

Patient and NHS benefits

My Discharge has dual benefits for patients and health and social care. Remaining in their place of choice for longer, dementia patients have a better quality of life. The NHS, meanwhile, saves vital funds through reduced hospital length of stay and readmissions.

Fran and Becky are optimistic that the My Discharge project will become a permanent service at the Royal Free and they’d like to see this case-managed approach used with other care providers.

*Names have been changed

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