How a change in practice can reduce hospital admissions for older dementia patients

Four years ago, as a newly appointed consultant old age psychiatrist working in Havering in east London, I was struck by the high clinical workload in the post, including multiple home visits and many admissions for people with dementia.

There are many reasons to try to avoid or shorten hospital admissions in elderly people with dementia. These include the concerns about the care for elderly people in general hospital wards and the difficulties in discharging people back to their own homes, leading to increased admissions to care homes. And, of course, older people prefer to continue living at home with support.

My main priority was to develop the support available in the community to avoid the need for admission. There was no master plan but more a series of small, complementary steps.

These proved effective. Looking at the number of inpatient admissions and the average length of stay, from April 2009 to March 2010, I found that the community team for which I was consultant had only 551 occupied bed days compared with 2,314 and 1,825 in the other two teams.

In that year, my team had only 19 admissions and only four for people with dementia in a population of 11,500 elderly. I was encouraged to make a comparison across all nine older people’s mental health teams within North East London Foundation Trust.

In Havering there are around 40,700 people over 65 years of age. Of these, more than 3,000 people have dementia with around a third of these living in care homes. The borough was covered by three community teams covering similar sized catchment areas.

My approach had three main elements. First, improving access to me as a consultant – the main sources of referral being primary care and the care homes as well as the community mental health team – improving training and development, and liaising between different services to prevent people falling through the net.

Working with GPs

I began working much more closely with GPs and practice nurses and made my mobile number freely available to them for advice and support. I tried to give GPs a same-day response for concerns about patients and I often visited the practice straight after doing an assessment to discuss issues with the GPs.

I supplemented this with talks at surgeries about common psychiatric problems in older people, including dementia and depression. I noticed an improved confidence in GPs, better quality referrals and improved clinical management.

I made an increased effort to develop close links with the care homes and again gave them all my mobile number and encouraged them to call me for advice and support. I ensured they got a prompt response, provided a series of training sessions and developed a number of regular surgeries at homes which had particular problems. This meant I was able to identify difficulties before a crisis point was reached.

When one care home was unable to cope I was able to liaise with an alternative home that was prepared to accept the person, avoiding the need for a complete breakdown of care and an urgent psychiatric admission.

These levels of support resulted in no admissions from care homes over a two year period.

I established a pattern of joint visits with the community team and aimed to be available five days a week for home visits, ensuring not only better patient care but also providing opportunities for the team to improve their knowledge and skills. They were certain of a prompt response from me in terms of advice and support.

Last, I made sure outpatient clinics could be used to support people in crisis by providing emergency appointment slots and frequent follow-ups for people who were acutely unwell so they could be seen every two to four weeks.

Patients and carers were encouraged to ring up in case of problems and at each clinic appointment were provided with a contact sheet with my secretary’s number.

Comparison across sectors

My team (team A) had only 16 admissions per 10,000 older people between April 2009 and March 2010. This graph shows the number of inpatient admissions for each of the nine North East London Foundation Trust teams per 10,000 older people.

The graph here shows the number of occupied bed days per 10,000 population for each team, ranging from under 500 (team A) to more than 1,800 in the year.

Team A is using less than half as many beds as any other team.

The Royal College of Psychiatrists suggested that for a catchment area of 10,000 older people around 15 acute psychiatric beds are required. The figures show all the teams were using only a third of this number.

Looking at the cost implications, inpatient spend for team A for the year was £0.179m, while the average spend for other sectors/teams was £0.576m each.

Team A made a saving of £0.397m which could potentially translate to a saving of more than £2m across a trust the size of North East London FT.

The approach is less about any particular strategy and more about combining all the elements in a systematic way so that each provides an incremental benefit and results in a service for the community which helps to minimise the risk of admissions and in so maintain and support people at home.

With thanks to Professor Martin Orrell, consultant old age psychiatrist and associate medical director for research and development at North East London FT and professor of ageing and mental health at University College London.