REACT project: an investigation of the active components of a specialist home treatment intervention to prevent hospital admission of people with dementia in crisis in the community

A dementia crisis is when a person with dementia presents to a public service in a state where they, or a family member, is at risk of serious harm or death.

They will present in a state of physical neglect, at risk of suicide, in squalid home conditions, with a carer unwilling or unable to continue caring, lost, exposed to abuse, or resisting/refusing services.

People with dementia in crisis can receive home treatment. However, it is not known which components of home treatment are essential to prevent hospital admission during dementia crisis.

Aims: To identify and understand critical factors in successful home treatment of a dementia crisis that prevents a hospital admission and to use this knowledge to improve the practices of a home treatment crisis resolution service in Wales.

A secondary aim is to develop a manual for home treatment in dementia crisis. We will then be able to test the impact of this model on hospital admission rates, in comparison to other models of dementia crisis management, in a follow-on study.

Question: What are the active components of a home treatment crisis resolution service and important context for the prevention of hospital admission in dementia crisis?

Plan: The research will be of mixed-methods case study design. It will be an in depth investigation of what happens leading up to dementia crisis and how it is managed either to resolution or outcome at six weeks.

It will compare two cases, management by a home treatment mental health crisis resolution team and management by an in-patient mental health service.

The comparison will include incidence and characteristics of dementia crisis managed by each service. Data will be collected in the following ways: - Medical record review of all referrals for home treatment and in-patient treatment of dementia crisis over a 12 month period
Observations of the management of patients in dementia crisis (total 60, 30 per case) - Interviews with patients and their carers post dementia crisis (total 30, 15 per case)

Perceived Stress Scale at first assessment and at interview - QOL-AD measure of quality of life at interview - interviews with professionals involved in dementia crisis management (max 30, 10-15 per case)

Focus groups with the home treatment team and the in-patient mental health team (total 2). The within case and cross-case analysis will evidence the active components of the home treatment crisis resolution team approach; the key treatments, behaviours, education and context important for home treatment to prevent hospital admission. It will also find out if the pathway to and characteristics of dementia crisis are similar for those managed by an in-patient mental health team and therefore if hospital admission might have been avoided with home treatment.

Benefits to patients, the public and the NHS The NHS in Wales is challenged by a growing elderly population and increasing hospital admissions. Solutions are needed now to the growing demand for hospital bed days. The project will develop an existing service to deliver only components of greatest value to patients ensuring scarce resources are used to best effect in preventing hospital admission.

We expect the research project to enhance the prudence of the service by 2019. We also expect a product of the research will be a dementia crisis home treatment manual that can be tested, disseminated and have benefit across the NHS within five years.