Despite being medically ready for discharge, many people living with dementia remain in
hospital due to the absence of a coordinated, dementia-informed transition plan – bringing many emotional challenges for the person living with dementia and their family.
This was the experience for Caroline, guardian for her 98-year-old grandfather who was
legally blind and living with dementia. His situation became more complex when he was
moved between care homes and hospitals due to escalating behaviours.
When a social worker at Royal Hobart Hospital referred him to the Hospital to Aged Care Dementia Support Program (HACDSP), delivered through Dementia Support Australia
(DSA), everything changed.
The program, now in 11 locations nationally, provides specialist support for smooth transitions from acute care back to home, or residential care. The DSA team created a
tailored plan, a more suitable care home was soon found and excessive medication was
ruled out.
The team also helped the family to document his personal history, preferences and triggers. On the day of the transition, a team member helped him decorate his new room with special items, like pictures of Model T Fords, and provided a toy companion cat, while Caroline completed the necessary paperwork.
Caroline’s grandfather became more settled; he even felt comfortable enough to nap in the
common area at his new care home.
Caroline shares, ‘Our family felt heard and seen from the start. The DSA team encouraged us to reflect on the progress being made to settle him. And my grandma’s feelings of powerlessness were legitimised throughout the process, no longer being his fulltime carer.’
Bethany Kings, DSA’s Head of National Programs HACDSP and Respite, explains, ‘It’s about providing quality care for Caroline’s grandfather, and empowering the wider family through education, like planning meaningful visits around his other activities to reduce stress.’
Caroline concludes, ‘I don’t think we could have expected a better outcome. It felt like an enormous weight had been lifted off our shoulders.’