North London Partners in health and care

Dementia support in care homes


North Central London (NCL) are adopting integrated care networks and working with a multi-disciplinary team approach through delivery of support to care homes in Enfield. Whilst the primary goal of health and social care services is to support people in their own home for as long as possible, if this is no longer possible, we must ensure that the best possible care is provided to those needing care homes. Older people in care homes are amongst the most frail, vulnerable and dependent populations in our communities. As well as physical health conditions, 80% of people living in care homes have dementia and people with dementia have worse outcomes when admitted to hospital.

Therefore, this report seeks to give commissioners, partners across health and social care and care homes a best practice example of how to remove barriers between primary and secondary care, physical and mental health, health and social care through an integrated multi-disciplinary team supporting care homes in Enfield called the Care Home Assessment Team (CHAT). CHAT is an integrated mental and physical health team of Community Matrons, Geriatricians, Consultant Psychiatrist and Mental Health Nurses, occupational therapy, a phlebotomist, a tissue viability nurse, pharmacists and has strong links to primary care and frailty networks, who support 39 care homes across Enfield.

Therefore, this report seeks to give commissioners, partners across health and social care and care homes a best practice example of how to remove barriers between primary and secondary care, physical and mental health, health and social care through an integrated multi-disciplinary team supporting care homes in Enfield called the Care Home Assessment Team (CHAT). CHAT is an integrated mental and physical health team of Community Matrons, Geriatricians, Consultant Psychiatrist and Mental Health Nurses, occupational therapy, a phlebotomist, a tissue viability nurse, pharmacists and has strong links to primary care and frailty networks, who support 39 care homes across Enfield.

The outcomes

  • There was 35% reduction (-2,118) in the total number of A&E attendances and non-elective admissions, compared with a 23% increase in Enfield’s 65+ year old non care home population. 

  • This equated to a 9% reduction in costs (-£598,671). Against a 34% increase in costs for the general population aged 65+ (+£7,113,284)

  • Falls leading to hospital attendance or admission were reduced by 7%

  • 99% of residents died in their preferred place 

  • 39% of residents have had their medication reduced or stopped 

  • 8,409 hospital attendances and 8,109 GP call outs have been avoided 

  • 7,606 care home staff and managers attended training on 59 subjects

Executive summary and report

To find out how this pilot project started and continues to deliver these amazing outcomes, read the executive summary and full report: