Abstract
Background: This project, born from collaboration between physiotherapy and psychology, aimed to improve outcomes for patients with dementia and cognitive impairment in hospital settings. The primary challenge was the high rate of discharges to care homes, which contributed to prolonged hospital stays, increased deconditioning, and reduced patient motivation. These outcomes were further complicated by complex discharge processes involving multiple agencies, placing additional strain on health and social care resources.
Between September 2022 and September 2023, data from 546 patient admissions showed that 22.5% involved those with cognitive impairment, and nearly 99% of these patients were discharged to care homes. Our goal was to reduce this discharge rate by 25% through a ""Home First"" approach, which focused on supporting patients with cognitive impairments to return home instead of moving to institutional care. This approach emphasised timely, safe discharges to home, allowing patients to remain in familiar environments with necessary support to enhance rehabilitation.
Approach: To achieve this, we adopted a Quality Improvement (QI) framework, engaging patients, caregivers, and staff to co-develop interventions based on health psychology principles. The COM-B model of behaviour change helped guide the design of interventions aimed at improving patient engagement with rehabilitation. Key interventions included staff education on cognitive impairment, the development of engaging activity packs for patients, and the introduction of group-based physical combined with elements of cognitive stimulation therapy (CST) to enhance patients' physical, cognitive and social capabilities.
The intervention was rolled out in phases, starting with pilot programs and employing Plan-Do-Study-Act (PDSA) cycles to refine interventions. Staff training was provided to improve understanding of cognitive impairment and its effects on rehabilitation, while activity packs were created to offer guidance on home safety, nutrition, and local resources. Group exercises incorporating physical and cognitive stimulation were introduced to enhance cognitive abilities and social interaction.
Results: By April 2024, the project showed promising results. Of the 83 patients involved, 42 (50%) were discharged home, marking a significant reduction in care home discharges. By June 2024, this figure had risen to 75%, with 36 out of 50 eligible patients discharged home. This progress represented a substantial shift in discharge practices, aligning with our 25% reduction target.
Patient and caregiver feedback highlighted improved satisfaction, with patients reporting better mobility, enhanced social interactions, and increased engagement in rehabilitation. Staff also expressed pride in providing holistic, patient-centred care that prioritised autonomy and well-being. The collaborative approach not only reduced reliance on care homes but also improved overall care quality and patient outcomes.
Implications: In conclusion, the "Home First" approach demonstrates the effectiveness of interdisciplinary collaboration in creating integrated care models. By engaging staff, patients, and caregivers in co-developing solutions, we achieved significant improvements in discharge outcomes, reduced system inefficiencies, and optimised resource use. This project highlights the potential for collaborative approaches to transform care pathways and improve both patient outcomes and healthcare system efficiency. Our next steps are to explore reductions in length of stay and costs to services.