Return to home or aged care following discharge from acute care or Emergency Department (ED) presentation

A hospital admission or ED presentation is a likely indicator of changes in functional and clinical status of a person with dementia.

Any changes in medical management during or following an acute hospital presentation should be communicated via the hospital discharge summary. If information is unclear or results have not been provided, it is important to follow up with the ward Nurse Unit Manager (NUM) where the person was admitted.

Changes in functional and clinical status of a person are likely to have occurred so general assessment are likely to be required as well as specific assessments based on clinical need. If the person has been regularly assessed, this will enable results on return to be compared with those from shortly before admission to ED or hospital to identify change.

To ensure changes are effectively communicated and acted upon a multidisciplinary case conference including the family, the GP and any aged care staff who will be looking after the person should ensure that the expectations regarding care and residents needs are understood by all people involved in the resident’s care.

Further information to assist in the preparation of a facilitated case conference, suggestions on who to include, and tools to assist in facilitating a case conference can be found using the menu.

Last updated 13 October 2015