Background
For residential aged care home (RACH) patients admitted to hospital, delirium is common and associated with a high burden of unplanned hospital readmissions resulting in increased patient distress, morbidity and mortality.

Problem
A 12-month audit showed 18% of patients from RACH with delirium during hospitalisation had an unplanned hospital readmission to our institution within 28-days following hospital discharge.

Aim
To minimise delirium complications and reduce preventable hospital readmissions in recently discharged RACH patients following delirium during hospital admission.

Method
A post-discharge follow-up pathway (RESPOND) was implemented at our institution to target RACH patients admitted with delirium during hospitalisation. Two rounds of education and engagement sessions were undertaken with stakeholders and inpatient units over a three-month period. The hospital Residential In-Reach service (Geriatricians and Clinical Nurse Consultants who assess RACH residents in their place of residence to avoid preventable hospital presentations) performed a delirium focused follow-up review of patients within 72-hours of discharge. An audit evaluating implementation was performed after five-months.

Results
20 patients were reviewed during initial implementation. No patients had a 28-day unplanned hospital readmission. Medication review resulted in medication adjustment or de-prescribing in 66% of reviews, and identification and management of delirium-related medical issues and complications occurred in 75% of reviews.

Conclusion
A routine post-discharge review for RACH patients hospitalised with delirium appears to reduce unplanned hospital readmissions within 28-days. Optimising post-discharge support for RACH patients is necessary and supports the next phase of extending this intervention on a larger scale with further evaluation of patient outcomes.