New Tool Helps People With Dementia Transition From Hospital To Community
NIHR-supported researchers at The University of Manchester have developed and evaluated a new tool to help people with dementia transition more safely and smoothly from mental health hospitals back to their communities.
The project, called SAFER-Dem, has been shown to improve the discharge process, align care with best practice guidance and address the specific needs of people with dementia.
The study, published in BMJ Open, is funded by the NIHR Three Schools Dementia Career Development Award and the NIHR Greater Manchester Patient Safety Research Collaboration (GM PSRC).
Many patients with dementia find leaving the hospital confusing and stressful, and feel they aren’t involved in the decisions being made about their care.
Patients and their families often report:
• Poor communication: not understanding the next steps or how to manage new medications.
• Feeling ignored: patients feeling like they don’t have a say in their own recovery plan.
• Overwhelming environments: busy hospital wards making it hard to process important information.
To solve this, researchers teamed up with people living with dementia, their unpaid carers, and hospital staff. Together, they co-designed a simplified checklist and guide specifically for dementia patients.
This new SAFER-Dem “care bundle” was developed in response to already-existing tools that seek to improve the quality and safety of care for patients in the NHS.
The NHS Improvement SAFER patient flow “bundle” was designed to reduce delays and improve patient safety in adult inpatient wards.
Following this, the research team developed a care bundle called SAFER Mental Health (SAFER-MH), which tailored the NHS SAFER bundle to the specific needs of mental health settings.
SAFER-Dem is the next step: a co-designed version of SAFER-MH that is clearer, simpler and dementia-inclusive.
Dr Natasha Tyler, Research Fellow at the University of Manchester who led the study, said:
“People with dementia often have difficult experiences when discharged from mental health hospitals. Many feel confused, unheard, or not involved in decisions about their own care. Staff also report challenges, such as lack of time, unclear communication and busy ward environments.
“We worked directly with people living with dementia, unpaid carers, and healthcare professionals to help improve the discharge process from hospital to community for people with dementia. Our study participants took part in workshops and interviews, where they tried out early versions of the SAFER Dem materials and gave feedback.”
Overall, participants felt that SAFER-Dem could:
• help improve conversations
• support shared decision making
• make the discharge process feel more person centred
• However, they also noted that people with more severe dementia may need more support or may not always be able to use the materials independently.
Co-author Professor Maria Panagioti from The University of Manchester said: “Our study shows that by improving the quality and consistency of discharge planning, SAFER-Dem has the potential to enhance patient safety, strengthen system resilience and support more timely discharges where appropriate. It may also help reduce avoidable readmissions by ensuring that patients leave hospital with the right support in place.
“The SAFER-Dem intervention is not just about speeding up discharge, but about improving how discharge is delivered – making it safer, more personalised, and more effective for both patients and the wider health system.”
