Developing a Transitional care Service within Perth City Psychiatry Of Old Age Liaison Team Perth Royal Infirmary Developing a Transitional care Service within Perth City

Introduction In 2010, the Scottish Government made a commitment to delivering a world-class dementia service to people with dementia in Scotland. Scotland's National Dementia Strategy identified a key change area within which there is to be a particular focus is: “In general hospital settings, by improving the response to dementia, including through alternatives to admission and better planning for discharge” (Scottish Government, 2010)

Change Fund The Liaison Team forms part of workstream 3 of Perth And Kinross Change fund Core objectives are: To enhance the Liaison teams’ accessibility with the Acute Hospital Setting To develop a Transitional Care service within Perth City locality for patients discharged from Perth Royal infirmary with Mental Health needs and/or cognitive impairment

Team progress Four fold increase in referrals Five fold increase in cognitive assessments completed within a Acute setting. Reduction in transfer to POA In-patient wards. 25% of patients in transitional care do not require on-going support.

The Aim of a Transitional Care service: To improve the patients’ journey including their post discharge care, through the facilitation of a timely and effective discharge and to prevent inappropriate readmission to the acute general or psychiatric hospital setting.

Mrs C Demographic Mrs C was an 85 year old women, living alone, admitted to hospital following an acute episode of shortness of breath. Daughter lives in the South of England She was referred to the psychiatry of old age liaison team for assessment of anxiety and mild confusion. Mrs C experienced a period of increased confusion prior to returning home following an internal move within PRI from the medical to orthopaedic wards Because of this increased level of confusion Mrs C’s daughter, ward staff and POA team unsure how Mrs C would manage on her return home

Mrs C Aim of Transitional Care service Home visit arranged for 1 day post-discharge to address concerns around how Mrs C’s increased level of confusion will affect her ability to manage at home OT to complete functional assessment of Activities of Daily Living in patient’s own home By addressing these concerns the POA Liaison OT aimed to facilitate a timely discharge from hospital and worked to prevent readmission to the inpatient environment

Mrs C Summary Mrs C managed better than expected on her return home OT’s functional assessment confirmed that she had the ability, skills and confidence to live at home Falls risk reduced Social isolation highlighted and discussed with Mrs C No referral to Perth City OPCMHT service was required (either for post D/C support or ongoing rehabilitation) Single visit and follow-up telephone call post-discharge were sufficient to support Mrs C’s discharge from hospital; to maintain her safety and independence at home and to reduce the chance of readmission to hospital

Mrs B Demographic Mrs B is a 81 year old lady who was admitted to hospital following a fall at home. She was referred to the POA liaison service due to her paranoia and aggressive behaviour towards nursing staff Mrs B was commenced on antipsychotic medication for treatment of delusional ideation secondary to delirium Mrs B declined onwards referral to community psychiatric services as well as any social care support

Mrs B Aim of Transitional Care service To monitor her mental health and to review her antipsychotic medication with a view to discontinuing To review Mrs B’s home situation in relation to her functional ability to live independently in her own home

Mrs B Transitional Care input During the transitional care period, the antipsychotic was discontinued, there were no further psychotic symptoms She remembered being paranoid and suspicious and was embarrassed about how she had behaved. However was reassured of cause of the behaviour Over the period of transitional care input, Mrs B’s level of functioning returned to her previous level

“The support and advice given was very helpful” Qualitative Feedback Comments received included: “OT spoke with genuine feeling towards me and didn’t treat me like an idiot” “Without your input, she’d (Mrs R) still be here (on the ward)” “OT arranged for a wheelchair to enable outings and was delivered very quickly” “The support and advice given was very helpful” “Thank you for coming to see me so soon after my discharge” and “Thank you for coming back to see me” “Its good that you get this support as a carer…. I don’t know if maybe I’m asking for too much e.g. carers 4x daily. I did ask (the Council) and was refused. I was visited at home and advised that 4x daily is what is needed. That support was really good as I was struggling. Carers 4x daily are in now – what a difference. Thank you.”

Discussion Continuity of POA Liaison team input while in hospital and on discharge home Once at home, a patient has a rapport with POA Liaison team member -  anxiety experienced When visited at home. This allows more accurate assessments of mental health and function on discharge home Faster discharge from the hospital environment POA Liaison team can offer a timely follow-up community visit to assess a patient’s function on their return home and address concerns raised during the inpatient assessment Better response should patient be re-admitted to hospital POA Liaison team has knowledge and experience of the patient’s level of functioning and social support at home ‘Transitional Care’ Seamless transition of care from inpatient to community environments Provision of specialist mental health assessment to complement hospital OT’s functional assessment POA Liaison team = Main Contact for mental health advice both pre and post-discharge Increased support for relatives

Conclusion Provision of a Psychiatry of Old Age Transitional Care service supports an appropriate, timely and effective discharge for older adults with mental health and/or cognitive difficulties Initial feedback from patients and carers indicates that they feel this is a valuable and supportive service.