Implementation of Crisis Dementia Care in the Community

Aim

To provide timely, specialist dementia crisis assessment combining biopsychosocial and  pharmacological approaches to avoid unnecessary hospital transfers.

Outcomes

• Since 2024, ODCS has received 122 referrals and treated 56 high‑risk individuals, enabling early deterioration detection, evidence‑-based crisis intervention, safer care at home, and reduced hospital utilisation with improved care giver wellbeing. The main symptoms experienced by 67% (38/56) ODCS patients included psychosis, aggression and agitation which was managed safely in their usual place of residence/ RACH
• 13.5 % (8/56) required hospital transfer
• 9.6% (5/56) were supported to transition to a new RACH from hospital?
• 9.6% (5/56) were supported by ODCS to remain at home until end of life.
• Improvement of BPSD such as agitation, aggression, psychosis was identified with a reduction in Brodaty severity scale ratings (1-5, 1=no Dementia, 5= Dementia with severe BPSD, from a mean tier 5 on admission to mean tier 3 at discharge.

Discussion

The concept‑testing phase of the ODCS shows that a geriatrician-led, MDT, in-place crisis model can be implemented into a community setting. Its success reflects a targeted response to a longstanding gap: the absence of rapid, specialist dementia crisis services outside hospital, where care is otherwise reactive and fragmented. An evaluation  is planned to inform next steps of the project.

Key enablers included:

1. ODCS being embedded within the OPEN, enabling seamless partnership with outreach and hospital teams.

2. A skilled workforce, geriatrician, NPs, CNs, Pharmacist, Social Worker, and Administration,  able to address medical, behavioural, and psychosocial needs of patients.

3. Rapid in home crisis intervention assists to reduce transfers to hospital that can worsen delirium and distress for both patients and their carers.

4. Active consumer and primary‑-care  involvement, strengthening continuity and supporting person‑-centred goals.

Lessons and limitations:

ODCS should continue to refine a clear vision and objectives, reviewing referral criteria, response timelines, and outcome targets to maintain fidelity as  demand grows. Geriatrician leadership remains essential given patient complexity especially for initiating, titrating, and monitoring psychotropics and other higher‑-risk therapies, and for high‑-stakes escalation decisions. Integration with wider services remains vital in the ODCS model, with defined hospital‑-admission pathways when community management is insufficient and ongoing consumer engagement to strengthen links with general practice, residential aged care, older persons’ mental health, and memory clinics.

From a workforce‑-resilience standpoint, ODCS like any small, high‑-acuity MDT is sensitive to leave and surge activity; cross‑-coverage arrangements and clear escalation protocols help mitigate variability across all roles.

Next steps

• Advance Outcome  Measurement: Standardise Brodaty and NPI data collection at admission and discharge, improve documentation completeness, and embed routine monitoring to demonstrate patient outcomes, carer impact, and system benefits.
• Prepare for Scalable Expansion: Develop  an implementation toolkit including eligibility criteria, referral pathways, governance structures, and role descriptions to support replication across additional MNH sites and, in future, rural and remote regions.
• Embed research into the evaluation to examine  healthcare utilisation and cost effectiveness of this novel approach to dementia care.
• To inform scale and spread of the service.
• Strengthen Workforce Capacity: Ensure ODCS has the right number and mix of geriatricians, Nurse Practitioners, Clinical Nurses,  Pharmacists, Social Workers, and Administration to meet current service demand and support future scaling across Metro North and beyond.
• Embed Workforce Resilience: Develop clear cross‑coverage arrangements, escalation pathways, and succession planning  to maintain service continuity during periods of leave, surges in referrals, or increased clinical acuity.

Where else in Queensland Health can you see this project succeeding The first phase of OPEN Dementia Crisis Service project has demonstrated that patients  with complex behavioural and psychological symptoms of dementia can be managed in community settings. Given the rising incidence of dementia-related crises and gaps in specialised community care, the ODCS model has strong potential for expansion across Metro
North.

Following its successful launch across Metro North, the ODCS project could be scaled and extended to include rural and remote facilities to help deliver timely, specialised behaviour support directly into the home.

References

Australian Institute of Health and Welfare. (2025, December 5). National Dementia Action  Plan indicators dashboard: Measure 1.4—People in regional, rural and remote settings have improved access to dementia diagnosis and support. https://www.aihw.gov.au/reports/dementia/ndap-indicators-dashboard/contents/action-1/measure-1-4-dementia-services-rural-areas [aihw.gov.au]

Brisbane North Primary Health Network. (2023, March). Health Needs Assessment – Fact sheet: Older persons needs (2021/22–2023/24). Dementia Australia. (2025, November 27). Home care. https://www.dementia.org.au/living-dementia/care-options/home-care [dementia.org.au]

Marsden, E. J., Taylor, A., Wallis, M., Craswell, A., Broadbent, M., Johnston‑-Devin, C., & Crilly, J. (2020). A structure and process evaluation of the Geriatric Emergency Department Intervention (GEDI) model. Australasian Emergency Care,  23(3), 149–155. https://doi.org/10.1016/j.auec.2020.05.006

Metro North Health. (2023). Annual report 2022–2023. Queensland Health. https://metronorth.health.qld.gov.au/wp-content/uploads/2023/10/ar-2022-2023

Morton, T., Wong, G., Atkinson, T., & Brooker, D.  (2021). Sustaining community‑-based interventions for people affected by dementia long term: The SCI‑-Dem realist review. BMJ Open, 11, e047789. https://doi.org/10.1136/bmjopen-2020-047789

Mutsekwa RN, Campbell KL, Canavan R, Angus RL, McBride LJ, Byrnes J. Performance Understanding and Learning System (PULSE-KEY): development of a framework for implementation and performance evaluation of healthcare delivery models of care. BMJ Open. 2024 Dec 20; 14 (12): e088663.

Thompson, S., Shukralla, H., Fyfe, K., Woods, J., & Fitzgerald, K. (2024, May 6). Dementia care: Action needed in rural Australia. InSight+. https://insightplus.mja.com.au/2024/17/dementia-care-action-needed-in-rural-australia/ [insightplu...mja.com.au]

Pond, D., Higgins, I., Mate, K., Merl, H., Mills, D., & McNeil, K. (2021). Mobile memory clinic: Implementing a nurse practitioner‑-led, collaborative dementia model of care within general practice. Australian Journal of Primary Health, 27(1), 6–12. https://doi.org/10.1071/PY20118

Reuben, D. B., Stevens,  A. B., Gill, T. M., et al. (2025). Patient and caregiver outcomes of health system, community-based, and usual dementia care: A prespecified analysis of the Dementia Care Study (D‑-CARE) randomized clinical trial. JAMA Internal Medicine, 185(10), 1227–1236.  https://doi.org/10.1001/jamainternmed.2025.4247

Zhu, E. M., Buljac-Samardžić, M., Ahaus, K., Sevdalis, N., & Huijsman, R. (2023). Implementation and dissemination of home‑- and community‑-based interventions for informal caregivers of people living with dementia:  A systematic scoping review. Implementation Science, 18, 60. https://doi.org/10.1186/s13012-023-01314-y