Emma Hughes explains the benefits of her role as a Transitions of Care Admiral Nurse, helping people living with dementia and their families navigate health and social care systems, support hospital admissions, and prevent readmissions.
I’ve been a nurse for over 30 years and have spent more than a decade working in dementia care. It’s only since becoming a dementia specialist Admiral Nurse nearly three years ago that I’ve realised just how difficult it is for people with dementia and their families to navigate the transition of care in to and out of hospital.
Dementia is a progressive condition which means that over time, caring for someone with it can become increasingly difficult and more complex. Being admitted to hospital can bring additional difficulties for someone with dementia as poor health as well as unfamiliar surroundings, staff and routines can be incredibly confusing and frightening.
‘At any one time, one in four hospital beds are occupied by people living with dementia’
At any one time, one in four hospital beds are occupied by people living with dementia..[1] People with the condition are at an increased risk of being hospitalised for a number of reasons: including delirium – a state of mental confusion that comes on suddenly – falls and a lack of social care provision.
On average, people with dementia experience hospital stays more than twice as long as those over 65 who don’t have the condition.[2] They are also at a greater risk of seeing a deterioration in their condition during their stay.[3]
Despite the best efforts of health and social care professionals, people living with dementia and their families often do not receive the specialist knowledge and support they so desperately need in hospital. This in turn means that when a person with dementia is ready to leave hospital, they often require additional support with 1-1 care, managing changes to behaviour, or needing practical adaptations to their home to enable safe discharge.
Trying to navigate the health and social care system, that is fragmented and complex, can cause many families to reach crisis point; not knowing who to turn to for help.
That’s where the Transitions of Care Admiral Nursing model comes in – designed to reduce the length of stay in hospital for people with dementia, manage an appropriate and timely discharge in partnership with family carers, and prevent hospital readmission.
‘It’s a privilege to be a Transitions of Care Admiral Nurse – a family’s only constant during a turbulent time’
I work as part of the Admiral Nurse Transitions of Care service in Devon, delivered in collaboration with Dementia UK, Livewell Southwest CIC and University Hospitals Plymouth NHS Foundation Trust.
Transitions of Care Admiral Nurses like me provide emotional and practical support for people with dementia and their families with the most complex needs, from the point of their hospital admission, through to after they’ve been discharged.
Acting as a bridge between families and health and social care systems that are complicated to navigate, a large part of my role focuses on bringing dementia specialist knowledge to the discharge process, ensuring the person with dementia ends up in the right place for them.
Once the person with dementia has been discharged, it can take a while for them to settle into their new environment – even if it’s the home they have lived in for years. To help ease this transition and prevent hospital re-admissions, I support the person with dementia and their family for six weeks after they’ve been discharged. This includes giving practical advice to care home staff on managing distressed behaviour and providing emotional support to family members.
Given the nature of dementia, there will be further challenges for families after these six weeks – but they’re not alone. I encourage families to call Dementia UK’s free Admiral Nurse Helpline, open seven days a week, or to book a virtual clinic appointment, where they can seek specialist advice and support.
‘Dementia UK is planning on expanding the number of similar services’
For me, it’s a privilege to be a Transitions of Care Admiral Nurse – a family’s only constant during a turbulent time. By being a family’s first port of call, I develop good relationships with the people I support, enabling them to express concerns on other aspects of dementia like end-of-life care or financial worries that they might not feel comfortable doing otherwise.
During a 20-month period, the Transitions of Care Admiral Nurse Service in Devon supported 320 families. An audit of the families supported during this time showed that there were no avoidable hospital readmissions, helping people living with dementia to stay in their home – where they tend to feel most comfortable and safe, and also saving the system money.
The Transitions of Care model has been used as an example within the High Impact Change Model (HICM) of how connecting health and social care systems has the greatest impact on patients. The HICM offers an approach to support health and care systems to deliver best practice, highlighting the changes in practice that will result in better outcomes for people living with dementia.
Following the positive outcomes Transitions of Care Admiral Nurses have had at both an individual and system level, Dementia UK is planning on expanding the number of similar services across the next two years to help support the one million people and their families who are estimated to be living with the condition by 2025.[4]
Emma Hughes is a Transitions of Care Admiral Nurse in Devon
Dementia UK is the specialist dementia nursing charity that is there for the whole family. For advice or support on navigating the transition of care for someone with dementia, contact Dementia UK’s free Admiral Nurse Helpline on 0800 888 6678 or email [email protected]
References
[1] https://www.hqip.org.uk/resource/national-audit-of-dementia-round-4-audit-report/#.XbmLBzY3aHt
[2] https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/fix_dementia_care_-_hospitals.pdf
[3] https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/fix_dementia_care_-_hospitals.pdf
[4] https://www.lse.ac.uk/cpec/assets/documents/cpec-working-paper-5.pdf
