Transitions to residential aged care after hospital for people living with dementia

Benefits of this study

This is the first study in Australia to use population-level linked data to examine transitions between hospital and residential aged care for people living with dementia and how this compared with people without dementia. As the data include all public hospitalisations and government-funded residential aged care admissions within most jurisdictions, results are representative of most Australians aged 65 or older who were hospitalised.

Using linked health, residential aged care and mortality data from multiple jurisdictions is a key strength of this study. It allowed for nearly seven years of clinical information to be used to identify whether people had a previous diagnosis of dementia, and almost 79,000 people living with dementia and almost 627,000 people without dementia aged 65 or older who were hospitalised in 2017 were identified. Using linked data also allowed for people’s transitions in care or mortality in the 7-days, 3-months and 12-months after discharge from their first hospitalisation to be examined. For the first time, this allowed the key clinical characteristics and use of health services 12-months after first hospitalisation to be examined by use of residential aged care before and after hospitalisation and by dementia status.

Specific findings, such as the substantial increase in length of stay associated with individuals awaiting entry to aged care (including where individuals already in aged care are changing facilities) and decrease in length of stay for people who used respite care to transition to residential aged care indicate a need for further investigation into the sources of delay and how these transitions may be streamlined to reduce hospital stay length. This is especially pertinent for people living with dementia given they were much more likely to transition to aged care (or move to a new aged care facility) compared with people without dementia. It is also particularly important to ensure hospital stays for people living with dementia are only as long as clinically necessary because the hospital environment can exacerbate the behavioural and psychological symptoms of dementia (Dementia Australia 2019).

There may be opportunities for earlier identification of people in hospital who are more likely to require aged care, such as people who are hospitalised due to dementia and people hospitalised due to a fall, so that processes to improve access to residential aged care and reduce the length of stay associated with delays can be implemented.

Community-dwellers living with dementia had longer lengths of stay compared with people without dementia and were more likely to present to the emergency department and have subsequent hospitalisations in the 12-months after discharge compared with aged care residents. These findings point to a greater need for comprehensive community-based dementia support services to allow people to leave hospital sooner in a clinically safe manner, and to support them to live in the community.

While almost everyone living with dementia had one or more GP consultations in the 3-months and 12-months after discharge, uptake of chronic disease management services and medication management reviews that are provided by GPs (in coordination with other health professionals) was relatively low. These findings may indicate missed opportunities to improve the coordination of care for people living with dementia.

Limitations and future directions

Future work to expand the linked data to include additional states and territories, private hospitalisations, community-based aged care services, eligibility assessments for aged care, and dementia-specific support services would provide richer information on transitions of care for people living with dementia. Incorporating information on community-based aged care programs into the linked data, particularly programs like transition care that provide short-term restorative care after a hospitalisation, is essential to understanding the hospital and aged care interface. Incorporating data from dementia-specific behavioural support services would also allow for transitions of care for people experiencing behaviours and psychological symptoms of dementia (BPSD) who received support to be examined. People experiencing BPSD are of particular interest because they typically have complex care needs, often have longer hospital stays and are more likely to transition to live in residential aged care (AIHW 2023a).

Future work to expand the linked data to incorporate richer sociodemographic information is also needed. This would allow the hospital and aged care interface for priority population groups such as First Nations people and people from culturally and linguistically diverse background to be examined. These groups face unique challenges to accessing health and aged care services, such as language barriers, accessing culturally safe health and aged care services, and health literacy. 

A previous AIHW report recommended incorporating supplementary codes for chronic conditions into the linked hospitals data (AIHW 2023b). This change will be implemented into later versions of NISHI and is likely to improve the identification of people living with dementia. It will be important for the current report to be updated, particularly as more contemporary hospitals and aged care data becomes available.

To develop and implement targeted strategies that improve transitions between hospital and residential aged care for people living with dementia, future research that can better understand the factors that influence these transitions is also needed. For aged care facilities, factors such as their facilities and resources, including availability of staff trained in dementia care, may determine whether they are able to accommodate people living with dementia. For people living with dementia these factors may include: the role of the person’s carer and living situation, their socioeconomic status, whether they live in regional or remote areas, whether available residential aged care facilities are acceptable to the person and their family or carer, their dementia type and stage, and the types of community-based health and personal care services they are receiving. 

Outcomes from recommendations relating to improving the hospital and aged care interface provided by the Royal Commission Into Aged Care Quality and Safety (Royal Commission) is another area of future research. Recommendation 66 of the Royal Commission called for improved transitions between residential aged care and hospital, whereby staff of aged care services should provide paramedics with current information on residents’ health status when an ambulance is called, and Australian State and Territory Governments should implement changes to hospital discharge protocols that improve the clinical handover to aged care services. Expansions to the My Aged Care portal from April 2023 now allow discharge planning staff at select hospitals to access a summary of people’s My Aged Care portal. This allows them to view people’s current aged care services and their latest aged care assessment and to upload hospital discharge summaries. Whether this initiative improves clinical handover from hospitals to aged care services should be examined as data become available. The impact of the COVID-19 pandemic on transitions between hospital and aged care, and whether the impact differed for people living with dementia compared with people without dementia, should also be examined as the data become available. Understanding the quality of transitions between hospital and aged care will require quantitative data at the service-level about the frequency of transitions alongside qualitative data about whether the communication provided in the care transition was sufficient to understand the person’s needs.