Title: Home or hospital for people with dementia and one or more other multimorbidities: what is the potential to reduce avoidable emergency admissions?
Funder: Department of Health and Social Care

Abstract: Older people with multimorbidities frequently access 999 ambulance services. In cases where a patient s multimorbidities include dementia, the risk of ambulance use, A&E attendance and hospital admission are all increased, even when a condition is treatable in the community. This is particularly important as patients with dementia tend to do poorly in the acute hospital setting and hospital admission can result in adverse outcomes. This study will provide an evidence-based understanding of how older people living with dementia and other multimorbidities are using emergency ambulance services to try to meet their needs. It will also provide evidence of how paramedics make decisions about taking this group of patients to hospital, and what resources would allow them to make more person-focused decisions to enable optimal patient care. This is essential information to inform the formation of the new urgent and emergency care networks described in the Five Year Forward View (e.g. p22 &ldquo;ambulance services empowered to make more decisions, treating patients and making referrals in a more flexible way&rdquo;), and the expectation that new care models will be tested and shared. At present the use of Ambulance Services by older people with multimorbidities including dementia (OPMID) is not well understood. However, a review by Buswell et al highlights the issue of inappropriate calls where an ambulance is a last resort or &ldquo;safety net&rdquo;. Recent work carried out by members of the applicant team identifies significant challenges faced by paramedics; crews sometimes convey patients to A&E knowing that this course of action is undesirable. This is an area of considerable importance given existing evidence that highlights the likelihood of hospital admission and the resulting potential for adverse social and clinical outcomes for the patient. This study will explore, in three phases, the potential to reduce avoidable emergency admissions for OPMID. This will be achieved by assessing the burden that OPMID place on the ambulance service, investigating the factors influencing paramedic decisions to convey patients to hospital and exploring potential alternatives that could avoid unnecessary A&E attendances and hospital admissions. Phase 1: Retrospective data analysis Quantitative methods will be used to explore how often ambulances are called to OPMID. The issues considered will be: time and resources associated with these calls; who the call was made by; primary and secondary reasons for the 999 call; frequency with which these calls result in OPMID being conveyed to hospital. Phase 2: Observational case studies We will use a phenomenological approach to focus on understanding why OPMID are conveyed to A&E when they have an injury or illness that could be treated at home or in the community. Detailed case studies will be compiled using a combination of observation, interview and documentation analysis, to study the factors influencing the paramedic decision-making process. Phase 3: Needs Analysis We will hold three nominal groups with paramedics to investigate and prioritise the resources that would allow emergency, urgent and out of hours care to be effectively delivered to a OPMID at home or in a community setting, rather than conveyance to A&E with the resulting risk of acute hospital admission. This proposal is part of a clear research trajectory, and builds upon two strands of earlier work by the applicant team. It will answer important questions relevant to improving the care of OPMID by investigating issues specific to the ambulance service that influence the risk of these patients requiring hospital care, instead of being cared for in or close to their own home. The results will inform important downstream investigations and feed into a larger ongoing programme of work to develop and evaluate the alternatives to hospital care.

Lay abstract: Older people with multiple health problems often call a 999 ambulance. Where one of these health problems is dementia, the risk of ambulance use, A&E attendance and hospital admission are all increased. It is important to try and reduce this, as patients with dementia tend to have poor outcomes when they are taken to A&E or admitted to hospital unnecessarily. This study aims to find out why older people with multiple health issues including dementia are taken to hospital by ambulance, instead of being treated in the community. This will build on earlier work to find the true burden of dementia on pre-hospital care. It will look at the length of time paramedics spend at the scene, factors guiding the decision to transport and alternatives to A&E visits and hospital admissions. There will be 3 phases of work: Phase 1: Analysis of existing ambulance service data from previous 999 calls. Phase 2: Observations of ambulance call-outs to patients with multiple health problems including dementia. Phase 3: An assessment of what could be provided in the community to avoid hospital admission. This proposal is part of an overall research plan, and will inform further investigations and future service delivery. We plan to study issues specific to the ambulance service that reduce or increase the risk of someone with dementia and other long-term health conditions requiring hospital care, rather than being looked after in or close to their own home. It contributes to a larger piece of work developing and evaluating safe and effective alternatives to hospital admission for people with dementia. This will lead to a reduction in the number of avoidable emergency admissions, and better patient outcomes, for example through the introduction of rapid response health and social care teams as described in the NHS Five Year Forward View (2014).

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: NEUROLOGICAL