DementiaRoadmap Wales

Promoting living well with dementia across Wales

Discharge

Discharge from hospital after treatment should be planned and carers or family should receive advance notice. Discharge preparations should begin as soon as the person goes into hospital. A Social Worker can advise on the suitability of residential or nursing care, or on ways of helping when the person returns home. An Occupational Therapist can assess the home environment to advise on any aids to help support the person living at home.

The hospital discharge process should include;

  • an assessment of the person's needs, living environment and support network
  • a written care plan that records these needs
  • confirmation that any required services are in place in time for the discharge
  • a system for monitoring and, if necessary, adjusting the care plan to meet any change in needs
  • an assessment to see if the person qualifies for NHS Continuing Health Care, this will ascertain w the balance of health and care needs and whether there is responsibility under legislation for the NHS to provide or fund an individual’s care provisions.

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  • John’s CampaignJanuary 15 2018John’s Campaign is about making carers of people with dementia welcome on hospital wards and reflects a positive attitude towards the importance of carers and sensitivity to their needs.
  • Cracks in the pathwayOctober 30 2014This report presents the findings of a Care Quality Commission review of the care people living with dementia receive as they moved between care homes and acute hospitals.
  • The £20 Billion Question – An inquiry into improving lives through cost-effective dementia servicesJuly 4 2011This report published by the All-Party Parliamentary Group on Dementia (APPG) explores the the evidence for cost effective models of dementia care. It makes recommendations to focus on early intervention and prevention to reduce early entry to residential care and reduce unnecessary hospital admissions.
  • Find me good careOctober 23 2012This website developed by the Social Care Institute for Excellence (SCIE) is designed to help people find the right care and support to suit their needs and lifestyle, whether at a time of crisis or as they plan for the future.
  • Hospital 2 Home resource packOctober 26 2012This resource is designed to make it easier for health and social care professionals involved in hospital discharge to support older patients in returning home safely after a hospital stay and reduce the risk of readmission to hospital.
  • The Triangle of Care – carers included: A guide to best practice for dementia careSeptember 4 2013The Triangle of Care is a model for dementia care that supports a partnership approach between the person with dementia, the staff member and carer. It is designed to ensure that carers are appropriately included and involved in the care of people with dementia, particularly in hospital settings.
  • National Audit of Dementia – third reportJuly 13 2017The National Audit of Dementia (NAD) (care in general hospitals) measures the performance of general hospitals against criteria relating to care delivery which are known to impact upon people with dementia while in hospital. The third audit collected data between April and November 2016.
  • Preparing for a Social Services Care Needs AssessmentMarch 28 2019Tips for people with Dementia on preparing for a social services care needs assessment can be found on the Alzheimers UK website, link below.  http://www.alzheimers.org.uk/get-support/legal-financial/dementia-care-needs-assessment  
  • Social Services Support for DementiaEven if you feel you don't need support now, it's a good idea to know what's available and plan ahead. The adult social services department of your local council can help with your personal care and day-to-day activities. The first step is to arrange a needs assessment.
  • NHS Continuing Healthcare and NHS-funded Nursing CareNHS Continuing Healthcare  If you have complex health and care needs, the NHS may cover the cost of all your care at home or in a care home, including the services you receive from the local council. This is called continuing healthcare and is funded ...

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