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High Impact Change Area B: Being equipped to prevent and respond to crisis – case studies

These case studies relate to High Impact Change Area B of the High Impact Change Model: Improving the timely and effective discharge of people with dementia and delirium into the community.

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B1: Mid and South Essex ICS: Dementia Intensive Support Team

Plan

The Dementia Intensive Support Team (DIST) provides intensive support to patients with dementia and suspected dementia, of any age, to prevent hospital admissions to both acute and psychiatric hospitals. The teams work with those with dementia or suspected dementia and are able to support rising risk not just crisis.

The team consists of Registered Nurses, Community Support Workers and allied professionals such as Occupational Therapists and Speech and Language Therapy (SALT) support service. After a person is introduced to the team for the first time, both the patient and their carers are able to ‘self-refer’ or call the team for advice when needed.

Implementation

The multidisciplinary team supports avoiding unplanned admissions to the local acute hospital by working closely with primary care, ambulance services, community team (mental and physical health), social care and any other professional. They are able to intercept patients with dementia who are suffering a mental health crisis to remain in their place of residence by providing timely assessment, diagnosis and treatment for up to six weeks. This service is available from 9am to 8pm, every day of the year.

The team also work in collaboration with acute, primary care colleagues and the community dementia services, to provide a clinical assessment and delivery service that facilitates earlier discharges or reduces length of stay for those patients with dementia or co-morbid dementia. The team works with the patient and carer across all environments to provide constancy and support whether this is patients home, residential care, acute inpatient, mental health inpatient or anywhere else the individual may be.

Outcome 

The system has seen a substantial reduction in Organic Mental Health inpatient beds and NHS long term stay facilities, reducing to a single specialist unit. The ability for patients and carers to self-refer reduces impact on primary care and secondary MH services, also reducing crisis, non-elective admissions and supported early discharge in all environments.

Contact

Spencer Dinnage, Operational Service Manager (EPUT), Ageing Well Steward (MSE ICS)

Email: [email protected] 

B2: North Central London: ‘Silver Triage’ Model

Plan

Like many other areas, North Central London saw a disproportionate number of emergency hospital admissions from people with frailty over 75 – especially those with dementia. Many people in this group, and their carers, would prefer to avoid being taken to hospital but ambulance crews often felt they had little choice, especially when patients had several pre-existing conditions, and they did not have a full oversight of their medical history.

The Silver Triage initiative in North Central London aims to ensure that older people living with frailty receive urgent care in their home setting if this is safe and in keeping with their wishes and preferences.

Implementation

In 2022 the North Central London Integrated Care Board approved the initiative, bringing together the London Ambulance Service and NHS trusts. Silver Triage enables specialist doctors (geriatricians) to advise and guide ambulance paramedics in assessing older people living in care homes. The doctors can also help access and coordinate community services to provide care at home if the person does not need to go to the hospital.

The ambulance service accesses the scheme through a single phone number. Paramedics explain the situation, the patient’s background, their initial assessment, and recommended plan. The specialist doctor can then add to this if they feel it would be appropriate and support the ambulance teams with helping to ensure the plan is put into action – for example, by liaising with teams of healthcare staff in the community to make sure they are involved.

Outcome

As a result of the Silver Triage service, there has been a significant reduction in patients in this group being taken to hospital by ambulance – it is now around 20 per cent compared to 75 per cent in 2018. The scheme began with care homes and, due to its success, has been extended to cover people living in their own homes who now make up a majority of those seen. Silver Triage is supported by paramedics – 100 per cent said they would use it again.