Pilot supports transition from dementia unit to care home

Aged care provider Life Care is participating in a transit scheme for people living with dementia.

South Australian aged care provider Life Care has welcomed seven residents from a specialist dementia care hospital setting as part of a trial with the state’s health department.

The Southern Adelaide Local Health Network developed the Memory Support Transition Team pilot and is leading the program from the Repat Health Precinct, where it has the state-run hospital-based Specialist Advanced Dementia Unit for people with high acuity and complex care needs.

The MSTT pilot – which launched in February – supports people with dementia who are receiving intensive specialist care due to their high acuity and complex needs to move from the SADU to aged care homes.

It is usually a six-week supported transition for these new residents, said Life Care residential operations manager Melissa Fox.

“SALHN decides who gets MSTT support, and usually that’s because someone’s had some code blacks or behaviours in hospital, which they’d be concerned about them settling in. They provide a six-week burst of services still under the public health system – and it can go on longer if they’re not settling in – that supports them to settle into residential aged care,” Ms Fox told Australian Ageing Agenda.

Life Care has received seven new residents under the program so far, and Ms Fox credits the growth of its MSTT intake to Life Care employing geriatrician Dr Miriam Cursaro in March to work across its five care homes.

“Without Dr Miriam Cursaro, the support of these higher acuity residents might not have been possible or we might not have felt confident in doing it because we didn’t have that geriatrician input,” Ms Fox said.

Dr Cursaro works with the MSTT’s geriatricians, occupational therapists and nurses to ensure a smooth transition for the new residents.

“I can provide that overarching guidance and support to Life Care,” Dr Cursaro told AAA. “They know that if there’s a patient, who following this transfer is starting to get unsettled, I can have another look at them, and give some guidance to the staff on site, which seems to be working quite well.”

“They’ve supported and successfully transitioned every consumer through that program. We’ve not had any bounce back to hospital, which is really great.”

Melissa Fox

Dr Cursaro’s role also involves providing guidance and direction to these residents’ general practitioners about any medications that need continuing or reviewing, she said. “These patients have taken months to settle potentially, getting the right combination of medication, so we have to be a bit cautious with adjusting medications but also bearing in mind the desire to minimise medications where possible.”

Colin Semmens, 77, is one of the pilot participants to find a new home at Life Care more than a year after being admitted to the SADU.

Mr Semmens’ wife Barbara used to have to make a 60-kilometre roundtrip almost every day to visit him. But Colin is now a 15-minute drive away at Life Care’s home in Aldinga Beach, where he can receive the same the high-level of specialist care as at the SADU.

“We are so pleased to be able to bring Colin closer to home and his family,” said Mrs Semmens in a statement. “The aged care home is wonderful, and the staff are all so kind and helpful. It really is like Colin’s living in his own home again.”

SALHN’s Clinical Director of Rehabilitation, Aged Care and Palliative Care, Professor Craig Whitehead said the MSTT works with aged care providers to develop tailored care plans and ensure smooth transitional pathways.

“Through this trial, we are able to partner with residential aged care providers such as Life Care to support individual patients, their carers and family members to give them the best opportunity to return to community living, either in home based or residential aged care,” Professor Whitehead said in a statement.

“We want our patients to reside in community living environments in residential aged care settings where possible, where they can continue their treatment with specialised support and avoid unnecessary hospital admission.”

Ms Fox said the program has been very supportive for new admissions and has achieved a 100 per cent success rate to date. “We’ve still had that contact with the hospital system. They’ve supported and successfully transitioned every consumer through that program. We’ve not had any bounce back to hospital, which is really great.”

Main image: Life Care resident and Memory Support Transition Team pilot participant Colin Semmens and his wife Barbara

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Tags: Dr Miriam Cursaro, featured, Life Care, Melissa Fox, Memory Support Transition Team,

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