1. 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

2. 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)

3. 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

4. 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.

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. “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.”

13. 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

14. 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.