Helen from Queensland asks, “What clinical and more general information should we provide to support a smoother transition to hospital for residents in our care?”  

I call this the gap between the ideal and the real. 

We know that transfers to hospitals can be unexpected so it can be useful to have a checklist of what might be important when making these transfers so you can easily access this information. Beyond information like the resident’s name, reason for hospitalisation, Next of Kin details and recent medical assessments, consider:  

• Reports from services like Dementia Support Australia which can provide useful insights to the Emergency Care Team and other hospital staff.  
• Behaviour Support Plans: if there are particular interventions that have (or haven’t) been effective your BSP is a great tool to share.  
• All care homes should keep a quick About Me or similar top 5 document about the person transferring to hospital. This will include things like their preferred names, significant people and places, and things that they enjoy talking about (football, tv shows).  
• Looping in the person’s regular General Practitioner so that they can be prepared to support when the resident returns to the care home.  
• Medication charts and other clinical documentation that will inform the ongoing care whilst in hospital. 

Ideally, we want to keep people in their familiar care setting but when this is not possible, we need to ensure we are building supports around them to maximise their quality of life and wellbeing.  

And when they are getting ready for discharge, DSA can support with behaviour support on site at the care home if there are concerns about placement. Effective communication between care home, acute care setting, family and friend carers but most importantly with the person living with dementia is fundamental here.  

For General Practitioners, if you need more support for one of your patients living with dementia you can access our GP Advice Service.

A/Prof Steve Macfarlane is the Head of Clinical Services at DSA. He is a geriatric psychiatrist and spent 11 years working as the Director of two metropolitan public-aged psychiatry services in Melbourne, prior to helping establish the Severe Behaviour Response Team in 2015.