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High Impact Change Model: Improving the timely and effective discharge of people with dementia and delirium into the community

This High Impact Change Model (HICM) offers a practical approach to support health and care systems to deliver best practice for an individual’s journey to, during and following discharge from an acute hospital.

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This resource has been developed with the support of the Department of Health and Social Care and NHS England.

Who is the HICM for?

This HICM is intended for use by ‘Integrated Care Systems’ (ICS), a collective term used to describe local partners inclusive of NHS bodies (including ICBs, NHS trusts and NHS foundation trusts); local authorities; social care providers; voluntary, community, faith and social enterprise (VCFSE) organisations; and other partners such as housing, who have a critical role in addressing wider determinants of health and wellbeing for individuals and communities.

ICS partners should focus on how to achieve the best outcomes for their population, through working together to plan, commission and deliver discharge services that are effective and affordable within the budgets available to NHS commissioners and local authorities, pooling resources where appropriate.

This framework consists of best practice guidance and a number of recommended actions that systems should consider in connection with their intermediate care services, and implement where appropriate locally and affordable within available budgets.

Executive summary

The model is focused on the care of people with a suspected/ undiagnosed or diagnosed dementia, and those where delirium is superimposed on dementia (i.e. when a person with pre-existing dementia develops delirium). This HICM builds on the High Impact Change Model for Managing Transfers of Care which was first developed in 2015, with the latest refresh in 2023, and addresses the specific challenges of caring for people with dementia and delirium superimposed on dementia.

At any one time one in four hospital beds are occupied by people living with dementia. People with dementia experience some of the highest levels of avoidable hospital admission, inconsistent approaches to assessment and care in hospital, long lengths of stay and delays to discharge. In addition, the hospital environment is particularly distressing for people with dementia and delirium, where there is not sufficient information about their pre-admission status, their care partners can be excluded from the decision making process, and admission can lead to worsening symptoms, hospital acquired disability and loss of independence.

ICS stakeholders have highlighted that the discharge to assess model and home first approach to hospital discharge are not applied consistently and fairly to people with dementia and delirium. Decisions made about people’s transfer of care from hospital can be inappropriate (e.g. deciding they have no rehabilitation potential) and lead to unnecessary (and sometimes life changing) impacts.

The HICM sets out an individual’s journey in eight ‘areas’ with respective changes that have been determined as ‘high impact’ for their contribution to timely and effective discharge. 

Eight High Impact Change Areas

A flow chart showing the eight high impact change areas.

A: Embedding effective support for unpaid carers

High Impact Change Area A target audience: Integrated Care Systems, education and training teams, community NHS and social care teams, Primary Care Networks; Voluntary, Community, Faith and Social Enterprise partners

A: Case studies

B: Being equipped to prevent and respond to crisis

High Impact Change Area B target audience: Integrated Care Systems, providers of community NHS and social care, local ambulance services, community, urgent response teams, community mental health teams, primary care, crisis resolution and home treatment teams, dementia crisis teams (where available)

B: Case studies

C: Managing presentations in the Emergency Department

High Impact Change Area C target audience: Integrated Care Systems, providers of community NHS and social care, urgent and emergency care leaders, acute hospital leaders, mental health liaison teams, crisis liaison and/or liaison psychiatry, fraily and geriatric teams

C: Case studies

D: Enabling timely identification and assessment in hospital

High Impact Change Area D target audience: clinicians/professionals with specialism in dementia, frailty same day emergency care leads, liaison psychiatry, geriatric care, frailty teams

D: Case studies

E: Improving the inpatient experience

High Impact Change Area E target audience: acute hospital leaders, ward managers, all staff providing care, and dementia champions

E: Case studies

F: Optimising the discharge process

High Impact Change Area F target audience: Integrated Care Systems, Care Transfer Hubs, Multidisciplinary teams involved in the discharge process; and Voluntary, Community, Faith and Social Enterprise (VCFSE) partners (for example, admiral nurses)

F: Case studies

G: Providing intermediate care that promotes positive outcomes

High Impact Change Area G target audience: Integrated Care Systems, intermediate care team leaders, community NHS and social care providers, and multidisciplinary teams in Care Transfer Hubs (including rehabilitation services, for example occupational therapists and physiotherapists)

G: Case studies

H: Facilitating ongoing, longer-term care needs

High Impact Change Area H target audience: Care Transfer Hubs, community NHS and social care, and Voluntary, Community, Faith and Social Enterprise (VCFSE) partners.

H: Case studies

The term care partner has been used throughout this document for carers of people with dementia, and is inclusive of family, friends, neighbours and professional carers who have a role in supporting care. The first section of this model recognises the important role and implication on unpaid carers (i.e. non-professional carers), also known as informal carers, and pertinent actions that can support them in their role.

The term ‘care partner’ aims to reflect the critical role that many caregivers play in providing physical and emotional support to partners, friends, family and neighbours who may need it. 

The model highlights the changes in practice along these parts of the journey that will have the highest impact on the effectiveness, quality and outcomes of care for people with dementia and delirium and the care partners that support them. 

Consideration of ‘high impact’ reflects the learning, operational experience and good practice established through extensive engagement of over 100 stakeholders including people with lived experience, senior clinicians, front line practitioners, managers and senior policy makers.

We thank these stakeholders for their commitment, enthusiasm and willingness to take part in numerous forums and working sessions. This extensive participation has helped capture the complexities and issues, providing a solid base for what the model sets out as the most impactful changes that systems can make.

Individuals from the following organisations have taken part in the development of the HICM

Each section of the HICM contains ‘Voices from stakeholders’ which lists a selection of relevant quotes captured from people who helped shape the model, expressing the views of people living with dementia and their care partners.

The HICM is set in the context of the NHS England FRAIL Strategy (2024) and should be read alongside recommendations from:

This tool complements both the NHS England Rightcare Dementia Scenario (2024) and the due to be published DHSC and ML Dementia 100 Pathway Assessment Tool which have a wider focus on optimal care for people with dementia and provide a mechanism for capturing and understanding the fundamental characteristics and specific requirements that are considered key to the development and delivery of service and care needs for people living with dementia and their care partners.

How to use the HICM

The HICM is designed to support ICS partners to self-assess on how local care and health systems are working now, and to reflect on, and plan for, action they can take to deliver improvements in care throughout the year. The action planning template allows systems to self-reflect on where they are at and create an improvement plan to address areas of development.

Download action planning template

The ICS lead identified to review the recommendations from this HICM should consider the key stakeholders locally that will need to be engaged with in order to provide meaningful solutions (examples of stakeholder groups for each ‘area’ are available within the action planning template).

Through this model, there is an opportunity to raise the ambition level and do something different to improve people’s lives, whilst ensuring a more sustainable health and care system. This sets a different standard for dementia and delirium care and relies on:

  • Leaders in ICSs prioritising delivering care differently and developing a system-wide culture to do so.
  • Frontline staff being empowered with the right skills, support and environment to act differently, supported through integrated working across all partner organisations.

Each of the eight High Impact Change Areas has content that is organised as follows:

Setting out the challenge:

  • Summarises the current challenges in this area and gives examples of the opportunities for change.

Voices from stakeholders:

  • Lists a series of direct quotes from stakeholders, who expressed the views of people living with dementia and those who care for them. For example, views on what the issues are, what is needed to fill the gaps and what impact this will have.

Outcomes:

  • A headline description of the two or three main outcomes to be achieved.
  • For each outcome, a list of the recommended activities that will achieve this outcome.
  • For each activity ‘how to’ statements summarising how to undertake the activity, where relevant.
  • Examples areas of measurement that would help measure if the outcome has been achieved.

Key message for ICSs

ICSs can use the HICM and the action planning template to reflect on whether the outcomes, and their related activities in the model are being met within their local area and recognise any priorities for change. This is an opportunity to deliver best practice, optimal care and much needed support for their population living with dementia, and the care partners that support them.

Enablers of change

Five enablers of change, which are cross-cutting themes across all eight High Impact Change Areas, have also been reflected within the model:

Spotlight Case Study: Greater Manchester

Overview

Greater Manchester Integrated Care Partnership is one of the largest and most complex integrated care systems, with a history of devolution and integration since 2016. NHS Greater Manchester (NHS GM) is the Integrated Care Board for Greater Manchester. The ambition is for Greater Manchester to be a city region where everyone has a fair opportunity to live a good life; has improved health and wellbeing; experiences high quality care and support where and when they need it and where everyone works together to make a difference now and for the future.    

There are two key programmes in Greater Manchester, Dementia United and the local Discharge Frontrunner programme. Although they have been initiated through different routes, the two programmes have worked together to develop relationships and share learning. In particular, Dementia United has served as a conduit for disseminating the learning and developments from the Discharge Frontrunner work, to partners across Greater Manchester. The local Frontrunner programme has in turn, been able to gain involvement from Dementia United via the Dementia Carers’ Expert Reference Group (DCERG) and people with lived experience; a valuable source of involvement and feedback from people who have experienced the challenges of a hospital stay, firsthand. 

Longer term, Dementia United as a well-established programme that incorporates a number of system wide initiatives, provides a central place to sustain aims to improve the provision and experience of person centred care closer to home, hospital stay and discharge beyond the life of specific time limited programmes such as the local Discharge Integration Frontrunner scheme. Dementia United will be seeking to build the recommendations from the Frontrunner programme into the refresh of its delivery plans and priorities for 2025 and beyond. 


For further information (and for a printable version of the HICM) please contact: [email protected]

Highlighted pages

High Impact Change Area A: Embedding effective support for unpaid carers

Target audience: Integrated Care Systems, education and training teams, community NHS and social care teams, Primary Care Networks; Voluntary, Community, Faith and Social Enterprise partners.

High Impact Change Area A: Embedding effective support for unpaid carers – case studies

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

Target audience: Integrated Care Systems, providers of community NHS and social care, local ambulance services, community, urgent response teams, community mental health teams, primary care, crisis resolution and home treatment teams, dementia crisis teams (where available).

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

High Impact Change Area C: Managing presentations in the Emergency Department

Target audience: Integrated Care Systems, providers of community NHS and social care, urgent and emergency care leaders, acute hospital leaders, mental health liaison teams, crisis liaison and/or liaison psychiatry, fraily and geriatric teams.

High Impact Change Area C: Managing presentations in the Emergency Department – case studies

High Impact Change Area D: Enabling timely identification and assessment in hospital

Target audience: clinicians, professionals with specialism in dementia, frailty same day emergency care leads, liaison psychiatry, geriatric care, frailty teams.

High Impact Change Area D: Timely identification and assessment in hospital – case studies

High Impact Change Area E: Improving the inpatient experience

Target audience: acute hospital leaders, ward managers, all staff providing care, and dementia champions.

High Impact Change Area E: Improving the in-patient experience – case studies

High Impact Change Area F: Optimising the discharge process

Target audience: Integrated Care Systems, Care Transfer Hubs, Multidisciplinary teams involved in the discharge process; and Voluntary, Community, Faith and Social Enterprise (VCFSE) partners (for example, admiral nurses).

High Impact Change Area F: Optimising the discharge process – case studies

High Impact Change Area G: Providing intermediate care that promotes positive outcomes

Target audience: Integrated Care Systems, intermediate care team leaders, community NHS and social care providers, and multidisciplinary teams in Care Transfer Hubs (including rehabilitation services, for example occupational therapists and physiotherapists).

High Impact Change Area G: Providing intermediate care that promotes positive outcomes – case studies

High Impact Change Area H: Facilitating ongoing, longer-term care needs

Target audience: Care Transfer Hubs, community NHS and social care, and Voluntary, Community, Faith and Social Enterprise (VCFSE) partners.

High Impact Change Area H: Facilitating ongoing, longer-term care needs – case studies