Hospital Discharge to Care Homes
Hospital Discharge of Older People with Cognitive Impairment to Care Homes
The scope of this document is confined to the safe and appropriate discharge of older people with cognitive impairment from hospital to a care home. It is a given, within the context of this document, that discharge to any other care setting has been deemed inappropriate as the result of a comprehensive geriatric assessment (CGA). A separate British Geriatrics Society (BGS) Best Practice Guide deals with the wider context of hospital discharge of frail older people.
Before being discharged from either a district general or community hospital the older person with cognitive impairment requires CGA to determine:
- The level of cognitive impairment
- The underlying diagnosis (cause of their cognitive impairment)
- Whether there are or have been any symptoms of delirium
- Presence of persistent behavioural and psychiatric symptoms of dementia (wandering, aggression, shouting, etc) to a degree which requires specialist dementia care or need to be addressed appropriately in some other way
- Whether this is the most appropriate care setting to be discharged to, taking in to account potential strengths and risks of alternative social care supports, including the position of spouse, partner, carer or immediate family (i.e. their best interests are being served)
- The individual’s capacity to participate in determining the appropriateness of their care needs and that where the individual is capacious their agreement to the discharge arrangements will be established
- To ensure that any other medical conditions are stable
- To ensure that appropriate follow up is arranged as necessary with either primary care, geriatric services or old age psychiatry services
- Appropriateness of medication (including anti-dementia drugs)
- Exclude or identify any degree of depression
- Ensure access to any state benefits
Geriatricians should be able to recognise, diagnose and manage most aspects of cognitive impairment, as it is not just one of the ‘geriatric giants’ but is implicated in most aspects of geriatric medicine (falls, Parkinson’s, stroke, etc). Through the CGA (that should be an integral part of multidisciplinary team working that is central to good geriatric medical practice), the “geriatric team” should be competent at determining the care needs of most older people with cognitive impairment, whether or not the individual has behavioural and psychiatric symptoms of dementia (BPSD) CGA will identify the individual’s care needs based on the medical diagnosis, their degree of social functioning and/or likely rate of decline, as well as the availability / appropriateness of other social care options.
It will not always be necessary for separate assessments to be undertaken by both the geriatric and old age psychiatry services. Where the complexity of the individual’s management is such that the geriatrician requires further expert advice, this should be available from the local old age psychiatry liaison service.
Collaboration between health and social services is also required to ensure that both services work together and appreciate the professionalism of each others assessments. An integrated plan which may also come within the scope of the Single Assessment Process (SAP) should be agreed and incorporate the views of key stakeholders (family / carers, and, if possible, the individual) other than the health and social care professionals.
The Nursing Home and Residential Home sector is dominated by the care of people with dementia. It is vital that all health and social care professionals should have basic training in older people’s mental health and that care home staff, in particular, have the relevant skills and competencies to care for any newly admitted resident. At a national and local level the British Geriatrics Society and Faculty of Old Age Psychiatry should work in collaboration to promote excellence in the care of all older people in care homes by using their influence as experts in health and social care of older people.
Sometimes residents will have been given a formal diagnosis of dementia, and sometimes not. We need to recognise that this is the reality of care, and that, when someone is given a formal diagnosis of dementia, they should not automatically have to move to a home providing specialist psychiatric care. Where possible, the care needs of patients should be met through tailoring provision appropriately, rather than having to move home. In other words, level of care should be determined by needs not by diagnosis. Residents in care homes should have the same access to specialist care as those living in the community. Thus, whilst all care homes require access to education and training to help them better understand and manage residents with dementia; not all care homes need to be specially registered as ‘dementia homes’.
An individual who requires transfer to a care home purely on account of their dementia and/or BPSD will require a care home with an appropriate number of beds registered in the appropriate specialist category. However, where a degree of dementia already exists (or develops whilst they are resident in a care home) and this does not constitute the main reason for care or involve providers meeting specialist needs, then the resident need not be in a specially registered bed.
Given the future demographic trends, which will result in increasing numbers of dementia sufferers, the BGS intends to work with the Commission for Social Care Inspection and other interested parties from health and social care to see how the inspectorates can contribute to promoting excellence in the care of older people. The BGS also intends to work with the Faculty of Old Age Psychiatry and the Royal College of Nursing to demystify dementia, dementia care, and the discharge planning process from hospital to care homes.
This document should be read in conjunction with the following BGS and Royal College of Psychiatrists, Faculty of Old Age Psychiatry documents and joint NICE / SCIE Guidance:
- Raising the standard: Specialist services for older people with mental illness. Report of the Faculty of Old Age Psychiatry, Royal College of Psychiatrists, London. 2006
BGS England Council