At Hampshire Hospitals Foundation Trust (HHFT) we identified a need to address the issue of ‘stranded’ delirium patients, patients who had no previous mental health history, had ongoing delirium and were otherwise medically fit for discharge but unable to go home because of their confusion and care needs.
We worked in collaboration with North Hampshire Clinical Commissioning Group (CCG) and Hampshire County Council to pilot a pathway modelled on a three-week structure with assessment being carried out cognitively and functionally in the community by a team made up of a consultant geriatrician, frailty specialist nurse and social worker.
Our experience of the pathway has been a positive one and patient and family satisfaction has been high. This is based on verbal feedback from family members – we have not conducted a structured, qualitative assessment of this.
Although the pathway primarily provides patients with a period of stable assessment within their home we found that patients generally improved on going home both cognitively and functionally with improvement in wellbeing compared with how they were in hospital. This was a subjective observation based on the assessors’ knowledge of the patients while in hospital and review at home. This period not only allowed assessment of the delirium per se, it also gave health and social care a chance to come together to
evaluate care needs going forward for patients.
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