Characteristics and Outcomes of a Frailty-Led Dementia MDT: Exploring the Evidence for Hospital Admission Avoidance

Introduction: The Jean Bishop Integrated Care Centre (JBC) operates a unique, primary care-led Dementia Multidisciplinary Team (MDT) specifically designed for patients living with frailty. Unlike traditional memory services, this model integrates dementia specialists with frailty practitioners to manage complex needs in the community. It is also attended by staff from third party sector (alzhiemers society), local CMHTs, social services and carer support.  This audit aimed to characterise the patient cohort, evaluate clinical outputs, and examine preliminary evidence regarding the MDT's role in preventing hospital admissions.

Methods: We conducted a retrospective audit of 39 randomly selected patients from the JBC dementia caseload. Data collected included Clinical Frailty Scale (CFS) scores, residence, referral pathways (proactive Comprehensive Geriatric Assessment vs. reactive crisis response), and clinical interventions. “Avoidance of escalation” (hospital admission, mental health unit placement, or care home breakdown) was measured using electronic patient record indicators and qualitative review of clinical notes.

Results: The cohort was predominantly severely frail (median CFS 7) and resided in care homes. Proactive referrals accounted for the majority of the caseload and were associated with greater efficiency, often requiring fewer MDT discussions to reach resolution compared to reactive referrals. Clinical outputs included medication optimisation in 59% of cases (predominantly Memantine initiation) and onward referral for Comprehensive Geriatric Assessment (CGA). Notably, 77% of patients showed documented evidence of avoiding further escalation of care, specifically acute hospital admission.

Conclusions: The frailty-led Dementia MDT demonstrates success in managing high-complexity patients and appears to drive significant hospital avoidance. However, current data relies on subjective clinical judgement and "tick-box" measures recorded at the point of care. Consequently, a new piece of work is required to move beyond these loose measures, aiming to objectively quantify admission avoidance and validate the economic and clinical efficacy of the proactive MDT model.