Transition from hospital care

Quality statement 8

Before a patient with persistent or resolved delirium leaves hospital, an individualised comprehensive care plan is developed collaboratively with the patient and their family or carer. The plan describes the patient’s post-discharge care needs and includes strategies to help reduce the risk of delirium and related complications, a summary of changes in medicines and any other ongoing treatment. This plan is provided to the patient and their family or carer before discharge, and to their general practitioner and other regular clinicians within 48 hours of discharge.

Purpose

To ensure patients with persistent or resolved delirium, their family or carer, and their general practitioner and other regular clinicians are informed about the diagnosis of delirium and about the treatment the patient will require after they leave hospital. Involving patients and family or carers in the development of the care plan allows treatment goals to be tailored to the patient’s needs and circumstances.

What the quality statement means

For patients

Before you leave hospital, a clinician will talk with you and your family or carer about your episode of delirium and the ongoing care you will need when you leave hospital. They will help develop a plan with you and your family or carer in a format that you understand. The plan sets out your goals of care and any extra care you need to stay well and avoid complications from delirium. This may include eating a nutritious diet and drinking enough water. The plan will describe ongoing treatments such as the medicines you need to take and if any medicines have been stopped or changed. It will also include any community support services you have been referred to. You will be given a copy of this plan before you leave hospital. Your general practitioner and other regular clinicians should receive a copy within two days of you leaving hospital.

For clinicians

Before the patient leaves hospital, develop an individualised comprehensive care plan with the patient and their family or carer, and provide them with information about delirium. In the plan, include the goals of care, strategies for managing persistent delirium, if present, and for preventing delirium recurrence. Include a plan for review by a specialist clinic, specialist or primary healthcare provider 10 days after discharge. Describe all ongoing treatments and any follow-up needed for any comorbidities. Arrange appropriate outpatient rehabilitation services when required. List all medicines that the patient needs to take, specifying the generic drug name, dose, reason for use and duration for each one. Explain why any medicines have been stopped or changed.

Advise the patient of ongoing support services in the community and provide contact details, as appropriate. Provide the care plan to the patient and their family or carer before they leave hospital and to their general practitioner, and other regular clinicians or care providers within 48 hours of the patient leaving hospital. Include information about any cognitive screening tests or assessment carried out in hospital, and when and where the patient should be reassessed, if appropriate. This is especially important for patients whose cognitive function may improve after discharge, to determine their ongoing level of function.

For health service organisations

Ensure that systems, policies and procedures are in place for clinicians to provide information about delirium to patients and their family or carer, and to develop an individualised comprehensive care plan with the patient and family or carer before discharge. The care plan should include the details of cognitive screening tests or assessments that were conducted and arrangements for follow-up care post-discharge.

Ensure that systems enable the plan to be provided to the patient’s general practitioner and other regular clinicians and care providers within 48 hours of discharge. Where systems allow, enable uploading of the discharge care plan to the patient’s My Health Record. This enables other clinicians to access the details of the patient’s hospital care, which can be vital for informing ongoing care in the community. Sharing information on the care provided in hospital is particularly important if the patient is discharged to interim care (rehabilitation hospital or respite aged care) before returning home or consulting their usual general practitioner.

For patients

Before you leave hospital, a clinician will talk with you and your family or carer about your episode of delirium and the ongoing care you will need when you leave hospital. They will help develop a plan with you and your family or carer in a format that you understand. The plan sets out your goals of care and any extra care you need to stay well and avoid complications from delirium. This may include eating a nutritious diet and drinking enough water. The plan will describe ongoing treatments such as the medicines you need to take and if any medicines have been stopped or changed. It will also include any community support services you have been referred to. You will be given a copy of this plan before you leave hospital. Your general practitioner and other regular clinicians should receive a copy within two days of you leaving hospital.

For clinicians

Before the patient leaves hospital, develop an individualised comprehensive care plan with the patient and their family or carer, and provide them with information about delirium. In the plan, include the goals of care, strategies for managing persistent delirium, if present, and for preventing delirium recurrence. Include a plan for review by a specialist clinic, specialist or primary healthcare provider 10 days after discharge. Describe all ongoing treatments and any follow-up needed for any comorbidities. Arrange appropriate outpatient rehabilitation services when required. List all medicines that the patient needs to take, specifying the generic drug name, dose, reason for use and duration for each one. Explain why any medicines have been stopped or changed.

Advise the patient of ongoing support services in the community and provide contact details, as appropriate. Provide the care plan to the patient and their family or carer before they leave hospital and to their general practitioner, and other regular clinicians or care providers within 48 hours of the patient leaving hospital. Include information about any cognitive screening tests or assessment carried out in hospital, and when and where the patient should be reassessed, if appropriate. This is especially important for patients whose cognitive function may improve after discharge, to determine their ongoing level of function.

For health service organisations

Ensure that systems, policies and procedures are in place for clinicians to provide information about delirium to patients and their family or carer, and to develop an individualised comprehensive care plan with the patient and family or carer before discharge. The care plan should include the details of cognitive screening tests or assessments that were conducted and arrangements for follow-up care post-discharge.

Ensure that systems enable the plan to be provided to the patient’s general practitioner and other regular clinicians and care providers within 48 hours of discharge. Where systems allow, enable uploading of the discharge care plan to the patient’s My Health Record. This enables other clinicians to access the details of the patient’s hospital care, which can be vital for informing ongoing care in the community. Sharing information on the care provided in hospital is particularly important if the patient is discharged to interim care (rehabilitation hospital or respite aged care) before returning home or consulting their usual general practitioner.