For many older Australians living with dementia, the period of moving from hospital to aged care or back home with extra support is especially difficult. They often face not only physical frailty, but also memory loss and confusion, which make it hard to understand and adjust to new environments and care routines.
The Hospital to Aged Care Dementia Support Program was developed by Dementia Support Australia (DSA) on behalf of the Australian Government in recognition of these challenges, providing a tailored approach that supports people with dementia and their families during a vulnerable time.
This initiative is part of a broader strategy to improve dementia care pathways and outcomes across the health and aged care systems. By facilitating smoother transitions, reducing hospital readmissions, and ensuring individuals receive the right care in the right setting, the program aims to improve both clinical outcomes and quality of life.
The Growing Challenge of Dementia in Australia
Dementia is one of the leading causes of disability and dependency among older Australians. According to Dementia Australia, more than 400,000 people live with dementia nationwide, and this figure is projected to double by 2058. Dementia not only affects memory and cognitive function, but also has a profound impact on behaviour, mobility, communication, and the ability to perform everyday tasks.
When individuals with dementia are admitted to hospital – often due to falls, infections, or sudden health deterioration, the experience can be deeply disorienting. Hospitals are fast-paced, unfamiliar environments can exacerbate confusion, anxiety, and behavioural symptoms. Once the acute issue has been managed, returning home or moving into aged care can become a daunting process for both the patient and their family.
This is where the Hospital to Aged Care Dementia Support Program plays a vital role.
Understanding the Program: Objectives and Scope
The Hospital to Aged Care Dementia Support Program is designed to provide targeted, person-centred assistance to older adults with dementia who are being discharged from hospital. The program works by:
- Bridging gaps between hospital discharge planning, residential aged care admission, and community-based support services.
- Providing specialist dementia expertise to guide health professionals, aged care workers, and families through complex decision-making.
- Ensuring timely and coordinated transitions to reduce delays in discharge, hospital readmissions, or inappropriate care placements.
- Improving continuity of care, so that vital medical, emotional, and social needs are not lost in handover between sectors.
The program is usually implemented through specialist dementia care teams, often comprised of nurses, allied health professionals, care coordinators, and dementia consultants who collaborate closely with hospital discharge planners, aged care providers, GPs, and family members.
Program Availability and Access
Locations
The program is available in selected locations, ensuring there is representation in every state and territory. These locations were strategically chosen to provide broad geographic coverage and ensure that people living with dementia across the country can benefit from specialist transition support, whether they are in metropolitan, regional, or remote areas.
For specific location details, families and healthcare professionals can contact Dementia Support Australia directly or consult local hospital discharge teams. The Aged Care Decisions team also stands ready to assist and provide relevant information as required to help support families.
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Who Is Eligible For Support?
To be eligible for the program, participants must meet the following criteria:
- Be an older person living with dementia
- Be a patient in a public hospital within one of the designated program locations
This eligibility ensures the program focuses on those most in need of support during the critical transition from hospital care into aged care services or home.
How to Access the Program
Access to the program begins in the hospital. When a patient living with dementia is identified as needing support, the hospital team refers them to Dementia Support Australia (DSA). This referral-based system ensures the program is well-integrated into the hospital discharge process and responsive to each person’s unique needs at the right time.
Once referred, DSA works in close collaboration with hospital staff, aged care providers, and community services to develop and implement a tailored transition plan. This plan is guided by a comprehensive needs assessment, which includes:
· A review of the patient’s cognitive status and behavioural symptoms
· Evaluation of functional abilities such as mobility, nutrition, hygiene, and communication
· Identification of emotional, social, and environmental needs
· Consultation with family carers and existing support networks
Based on this assessment, the dementia support team creates a personalised plan that includes:
· The most appropriate care setting after hospital (e.g. home with services, respite care, or residential aged care)
· Dementia-specific support strategies, such as memory programs, environmental modifications, or behavioural interventions
· Coordination of home care packages or aged care placements
· Information sharing with aged care providers regarding the patient’s preferences, daily routines, and communication needs
Importantly, support doesn’t end at discharge. The program provides ongoing follow-up for up to three months after leaving hospital, helping to adjust care plans as needed and ensure a smoother transition into the next phase of care.
Why it Matters
This program supports not just the individual with dementia, but also hospital and aged care staff, families, and carers by providing expert guidance:
· During the hospital stay
· While transitioning out of hospital
· After discharge, as the person settles into a supported aged care environment
By ensuring continuity of care and personalised support, the program plays a vital role in reducing confusion, distress, and avoidable readmissions during a critical time in the care journey.
Supporting Families and Carers
Families are often the backbone of care for people living with dementia, and the emotional toll on caregivers can be significant. The sudden hospitalisation of a loved one, followed by the complex decision of moving into aged care or arranging services at home, can be overwhelming.
The Hospital to Aged Care Dementia Support Program provides families with much-needed guidance and emotional support. Families receive:
- Clear, practical information about care options and funding mechanisms
- Emotional reassurance and professional advice to aid decision-making
- Help navigating My Aged Care and other government programs
- Support for managing difficult behaviours or changes in the person’s condition
By including families in planning and offering tailored communication, the program ensures that decisions reflect the values, preferences, and unique histories of each individual and their loved ones.
Benefits and Early Outcomes
Emerging data and anecdotal evidence from pilot programs and implementations across Australian states suggest several tangible benefits from this initiative:
- Reduced Hospital Readmissions
People with dementia are more likely than others to be readmitted to hospital soon after discharge. The program helps prevent this by ensuring they leave hospital with a strong, well-organised support system in place.
- Improved Care Continuity
By communicating a person’s needs clearly to the receiving aged care facility or home care team, the program helps prevent critical care information from being lost in the transition.
- Timely Discharge and Reduced Length of Stay
Hospital beds are a limited resource. Ensuring that patients with dementia can be safely discharged to the right care setting helps reduce unnecessary hospital stays and improves system efficiency.
- Better Quality of Life
When older adults with dementia are moved into environments that are prepared to meet their unique needs, they tend to show less distress, fewer behavioural challenges, and greater engagement in meaningful activities.
- Greater Support for Aged Care Staff
Aged care homes benefit from receiving comprehensive handover documentation, training, and behavioural strategies that help them care for new residents with dementia more confidently.
The Hospital to Aged Care Dementia Support Program is a vital step toward a more responsive and inclusive aged care system. By recognising the specific vulnerabilities of people with dementia during transitions in care, the program offers a compassionate, coordinated approach that improves outcomes for individuals, supports families, and eases pressure on health and aged care services.
As Australia continues to confront the challenges of an ageing population and increasing dementia diagnoses, programs like this will play a key role in shaping a more humane, effective, and integrated model of care.
For more information, contact HACDSP@health.gov.au
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