How to navigate transitions in care

Meet Jack, a person living with dementia receiving care in hospital. We see daughter-in-law and primary carer, Emily, use tools and strategies to communicate Jack’s unique needs and routines so that they are known and understood by hospital staff as they care for him.  

What to consider

• Hospitals are noisy, busy, and have lots of flashing lights which may be unsettling for someone living with dementia. Minimising these can help.
• Sharing information about a person’s likes, dislikes and everyday routines can alleviate some of the distress he or she may experience, and help hospital staff support them. Dementia Support Australia's ‘About Me’ resource can help you with this process.
• Navigating the next steps as you think about discharging the person living with dementia can be overwhelming. You are not alone. There are many supports and services to help you – including social workers and My Aged Care
  

Jack, who is living with dementia, is preparing to move out of hospital into residential aged care. The hospital staff are equipped to collect relevant information about Jack’s stay in hospital, including their best care and behavioural support approaches. By collaborating with the residential care team and family, hospital staff can support a good transition into Jack’s new environment. 

What to consider

• Hospital staff know lots of valuable information about changes in the person’s care needs and behaviour support strategies that have worked in the hospital. Documenting these within discharge summaries and behaviour support plans will help with the handover process.
• Planning a discharge is important. Allowing time to prepare a comprehensive handover will ensure the process isn’t rushed and with enough time to become familiar with a new environment after hospital.
• Involving the person’s GP in discharge conversations and updating the GP on any changes to care needs or medications will help ensure continuity of care
  

Emily and her family are supporting Jack to move into residential aged care. It takes time to learn how to best support Jack, particularly as he gets to know new people and a new environment. Using the ‘About Me’ resource, Emily can document the things Jack likes, or doesn’t like, and how residential care staff can best get to know him. Communication between Jack, his family and care staff helps to ensure that his unique needs and preferences are known. This helps smooth out any uncertainties associated with the move into this new environment. 

What to consider

• Moving to residential care is commonly a stressful time for everyone involved because there is a lot of change and much to consider. Remember, you are not alone – there are many people to help you.
• Becoming familiar with the care home environment, the people who work there and the routines, is a helpful first step. Arranging to visit the home before the patient’s discharge from hospital could help to create a familiar environment.
• While it will never be ‘home’, you can make the space more familiar by taking in special items such as a favourite quilt, personal photos, and other memorabilia, or items of cultural or religious significance.  The best time to do this is before the patient moves in, so that it feels more familiar on arrival
  

Residential care staff are keen to support Jack to settle into his new environment. They do this by understanding how he likes to be cared for, and proactively responding to changed behaviours which Jack may experience during the transition to a new home and people. 

What to consider

• Planning an admission is important and timing is key to a successful admission. It may take some time to get to know someone living with dementia and at first it may be hard as they settle in. Best to plan an admission for a time and day that extra support is available – such as management and support staff.
• Seek out information from the hospital staff about how they have been able to care for the person while they were in hospital. This will become useful information as you build a behaviour support plan.
• Each person is different, so it is important to get to know their individual preferences. Ask the person themself or draw on family and friends to give you valuable insights into the person’s life and history
  

There are many resources to help people move from one care setting to another. We hope the following resources are helpful as you navigate change.

• A Guide for Family Carers: Dealing with Behaviours in People with Dementia
• About me: In brief and In depth resource
• Behaviour Care Planning Process
• Considerations for looking after a patient with dementia in an acute care setting
• DSA Overview Brochure
• DSA Travels All Over Australia
• Matters to be set out in Behaviour Support Plans template
• Understanding agitation helpsheet
• Understanding distress during personal care helpsheet