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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, urgent response teams, community mental health teams, primary care, crisis resolution and home treatment teams, dementia crisis teams (where available).

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Setting out the challenge

Professionals responding to crisis are often faced with making decisions based on the information available to them, and their ability to distinguish between a person experiencing a mental health crisis (i.e. the person does not feel able to cope or be in control of a situation) or a physical health crisis alongside their dementia that needs to be addressed (e.g. UTI, pain) – and when both are presenting at the same time.

Delirium (a sudden change over 1-2 days in a person’s mental state) is sometimes mistaken for worsening dementia or, more rarely, depression. Having dementia can make people more likely to experience delirium, and delirium may accelerate cognitive decline in patients with dementia. Delirium is treated by resolving the underlying physical health problems that have caused it and is reliant on someone noticing that the person is not themselves, or that there has been a sudden change in how they think or behave. Presentation with delirium is further complicated when there is no dementia diagnosis.

The Community health services two-hour urgent community response standard (2022) sets out that increased or new confusion, acute worsening of dementia and/or delirium should be covered under the 2 hour UCR response. ICS stakeholders have reported that UCR teams are able to manage the acute physical illness, but are not equipped with the skills to manage this in the context of dementia. These services are provided from 8am-8pm and therefore do not cover provision in the late evenings, where an ambulance service is more likely to be called. Local Community Mental Health Teams (CMHT), will be able to respond to the mental health needs of the person, however the response time can vary, i.e. they may take up to seven days to respond.

Consequently the people with dementia and an acute physical illness (including those experiencing delirium) that require a same day response, fall between the gap, which often leads to an Emergency Department attendance.

Voices from stakeholders

You need a plan in place before you reach the crisis, so that when something happens, it can be put in place as a protocol. Coming up with a plan in crisis is harder."

Crisis is often driven towards acute hospitals, as without a cohesion between teams and the right information to support decision making in the community, professionals often don’t know alternatives for how to manage these patients."

Delirium is preventable, can be managed in the community and those looking after people (whoever they may be), need the skills and confidence to deal with the issue as it presents. We don't expect them to manage it (recognising that it is complex) but to have the skills to support themselves in responding to it."

Outcomes

B1. Reduced likelihood of admissions and readmissions through proactive crisis support planning.

[B1.1]: Embed processes that proactively encourage people with dementia to develop a plan, and for teams that support the person to review them. The plan should be owned by the person, within input from their care partners, and be made visible to the teams that support them.

This will:

  • provide clarity on which care plans should be used as standard based on the progression of dementia within the ICS, and what level of detail is required to ensure the person’s care and support needs can be met. For example, this can include decisions or refusal of treatment and preferred places of care (i.e. if they never want to go to hospital)
  • provide a guide for where (in other words, which care setting) the care plan should be initiated, by who and how often it should be reviewed. This could include a prompt to develop a care plan, where it is not in place or to review one where a recent review is not documented
  • recognise that plans may vary depending on the paradigm the person is in (e.g. Universal Care Plan, that is bespoke for dementia needs; Advanced Care Plan, for use in palliative care/ end of life planning; ReSPECT form, that describes personal preferences in emergency care) 
  • consider how these plans integrate into existing systems (interoperability) or are accessed by different care settings (visibility), including out of hours providers 
  • consider how the plan will be adopted, implemented and reviewed, to ensure decisions are made in the person’s best interest, based on their wishes and preferences 
  • consider how the plan can be used in conjunction with expert advice, in other words, shared decision making, through a single point of access for the responding professional. 

[B1.2]: Develop and provide a repository of information and tools (e.g. action cards), that can support crisis planning, including the early identification of signs of escalation

 The information and tools could: 

  • be available to people, e.g. patients, care partners, care homes, and homecare/ domiciliary care/ independent care providers, who will have the most contact with the person
  • be shared widely with professionals and teams involved in the care of people with dementia and delirium, across all partner organisations in the ICS. This information should empower staff to recognise signs of deterioration
  • include descriptions on changes in behaviour, what to expect, how to identify worsening dementia, the difference between dementia and delirium and mechanisms to prevent deterioration (in other words, what is a baseline position and what happens when you notice a change in behaviour)
  • include who to contact and when, in line with a person's individual plan. This should also include links to advice and guidance e.g. through national VCFSE sector helplines, prior to crisis support where appropriate 
  • build upon wider staff skills training, required for the teams involved in crisis response. This includes the skills of being able to manage a crisis, taking on board information from a range of people that know the person best and who can best support them in distinguishing between a worsening dementia and delirium.

Supporting resources for proactive crisis support planning

B2. Access to comprehensive escalation support when in crisis

[B2.1]: Identify the community teams that are able to respond effectively to the presenting needs of someone with dementia (and those with superimposed delirium). This should include the UCR team, and any additional community services that are able to respond. Ensure these teams are known and communicated.

The team could:

  • be able to provide a same-day response
  • be multidisciplinary, with the right skill mix to respond effectively. The team needs to include, for example, professionals from healthcare (mental and physical), social care, the VCFSE care sector, therapy, ambulance services and housing. They should be linked into other established MDTs for further advice and guidance where required
  • be skilled in understanding the presentation of person with dementia or delirium
  • be skilled in effective communication, especially where the response is formed of professionals from different organisations. An example of effective communication would be sharing a verbal update on a person’s status before a visit, utilising a shared record or team notes. Also consider co-location of professionals/teams as a way of facilitating effective teamwork or spending time with the community teams in order to build relationships, gain trust and understand how they operate 
  • be able to refer into services in the local area that keep the person at home with wrap around support to prevent an avoidable admission to hospital
  • be accessible via extended hours, to mitigate unnecessary escalations to the Emergency Departments. 
  • have access to assistive technology, i.e. to items that are used to maintain or improve functional capabilities, such as electronic pill boxes, and to point of care testing (enabling medical testing at or near the site of patient care by specially trained professionals e.g. blood or urine samples) 
  • have a culture that prioritises the need to keep people at home where possible, adhering to a higher threshold for admission to acute hospital, as part of a shared decision making process that is driven and supported by leadership
  • have a ‘one team’ ethos, irrespective of parent organisations, to work around the person (i.e. you do not have to have the same manager to work as a team).

[B2.2]: Identify and communicate how the community teams responding are able to rapidly access specialist advice (e.g. highly trained clinical specialist, Consultant Geriatrician or Consultant Psychiatrist).

  • Take stock of existing service models where access to specialists already exists (e.g. single point of access, UCR, virtual wards, virtual frailty unit, frailty MDT) and recognising the requirement for integration between physical and mental healthcare services to deliver the appropriate response.
  • Consider how the current model best fits within any proposed changes following review of the HICM, including overall delivery of a crisis response that maximises efficiencies for specialist input. 
  • Build in the specialist advice as part of shared decision making (e.g. local ambulance service, CMHT, Mental Health Crisis teams, Enhanced Health in Care Homes multidisciplinary teams, highly trained clinical specialist in mental/ physical health) to keep the person safely at home. 
  • Communicate any changes made with all system partners who would benefit from shared decision making when considering the best option for the person (e.g. ambulance services). 

[B2.3]: Identify and communicate how the community teams responding can have rapid access to diagnostics (and what these diagnostic tools should be). 

  • Taking stock of existing service models that enable diagnostics without a hospital admission (e.g. single point of access to determine diagnostic, using a ‘hospital at home’ approach, acute frailty unit, same day emergency care, community diagnostic hubs). 
  • Wherever possible keep the person at home or as near to home as possible, and identify how the person could be brought into and out of the diagnostic space without getting admitted (e.g. with a nominated advocate lead for transition in and out). 
  • Consider how the diagnostic will be used in conjunction with shared decision making in the team to provide an alternative route for the person as part of the wider pathway.

[B2.4]: Identify the teams to contact in hours, out of hours and on the weekend for support for physical and mental health, where otherwise an admission is most likely.  

  • Outline services that are available as a step-up in the community, their hours of operation and what they provide. 
  • Ensure that these teams are able to communicate with each other (e.g. physical and mental health teams) to deliver the best outcomes for the person. 
  • Identify a point of contact/ telephone line that can be contacted in the case of an escalation/ in crisis. 
  • Ensure that people awaiting a diagnosis have access to crisis support, and are not unfairly discriminated against. 
  • Provide details of VCFSE help and support that is available nationally, including 24/7 services for support during the night. 
  • Consolidate this as part of a wider set of resources that are available to people and their families, care partners etc.

Supporting resources for comprehensive escalation support 

VCFSE services for support and guidance