Download Dementia Recognition and Management event

Dementia
Recognition &
Management
Tuesday 13th October 2015
12.30 to 5.30pm – Arora Hotel Crawley
Introduction
Dr Caroline Jessel (Chairperson)
Housekeeping
• Parking (available under the hotel – barrier will
go up at 5.30 so no need to pay. If need to
leave earlier then get pre-validated ticket from
Jo Gavins
• Phones – please switch to silent or off during
event
• There will be allocated slots for Q & A
Agenda
•
12.30 – 2pm
•
2.00-2.05 Introduction - Dr Caroline Jessel (Chairperson)
•
2.05-2.20 National Perspectives
NETWORKING LUNCH
Professor Alistair Burns (National Clinical Director for Dementia)
•
2.20-2.30 Q & A
•
2.30-2.45 Dementia Data Harmonisation and QOF/READ Codes
Dr Jill Rasmussen (SE SCN Clinical Lead for Dementia)
Joanna Gavins (SE SCN Interim Programme Manager for Dementia)
•
2.45-3.00 Case Findings, Care Homes and Care Planning
Dr Jill Rasmussen (SE SCN Clinical Lead for Dementia)
•
3.00-3.05 Q & A
•
3.05-3.30 TEA BREAK
National
Perspectives
Professor Alistair Burns
National Clinical Director for Dementia
Dementia
Alistair Burns
66.1%
31 August
NHS England’s Dementia Plan
Five components:
•
•
•
•
•
Regional and Area Team
Support to CCGs
Improving Data eg
harmonisation of clinical
records
Proactive Communications
Intensive Clinical Support
(Ambassadors)
Enhanced services
Bristol Primary Care Dementia Service
Bristol CCG has transformed their dementia care
service from being managed entirely within
secondary care to one delivered predominantly in
primary care with support from specialists. Feedback
from GPs, patients and specialists has been
overwhelmingly positive.
Models of Dementia
Assessment and
Diagnosis: Indicative
Cost Review
Dementia Scorecard: crosswalks and metrics
Preventing Well
Diagnosing Well
Supporting Well
“i” Statements
I was given information
about reducing my
personal risk of dementia
I was diagnosed in a
timely way
Those around me and
looking after me are
supported
NICE Guideline
Prevention
Diagnosis and assessment
Integration
NICE Quality
Standard 2010 (1)
Memory Assessment
Living Well
Dying Well
I feel included and I am I am confident my end
treated with dignity and of life wishes will be
respect
respected
Promote independence Palliative care and pain
Choice
Carers, Respite,
BPSD(3)
Care Plan, Information
Palliative Care
Liaison
NICE Quality
Standard 2013 (2)
Concerns Discussed
Needs
Advocates, Housing,
Choice, Relationships,
Leisure,
Community
NICE Pathway (1)
Services
Investigation
Information
Supporting Carers
Intergrated Services
Choice, Independence
Living, Hospitals
Treatments
End of Life
Supporting Carers
Social Care
Co-ordinated Care
Safe Communities
Environments
Technology
Health Services
Preferred Place of
Death
Dementia friends
PLACE
To be developed
?place of death
OECD
Risk Reduction
Diagnosis
Metric(s)
Vascular Risk
Diagnosis Rate
Enhanced Service
QOF Reviews
John’s Campaign
(1) Training - common to all areas. (2) Includes wellbeing and choice evaluation (3) BPSD – Behavioural and Psychological Symptoms of dementia NICE Guidance on risk reduction
imminent
Post diagnostic support
Peri-diagnostic support
Care planning
Did it happen?
Did it help?
Meaningful care
Care planning
D Diagnosis review
E Effective support for carers review
M Medication review
E Evaluate risk
N New symptoms inquiry
T Treatment of medical conditions
I Individual issues
A Advance care planning
Dementia Friends
www.dementiafriends.org.uk
Further thoughts
•
•
•
•
•
•
•
Dementia as a long term condition - the new diabetes?
Breaking down primary secondary care barriers
GPs diagnosing dementia, starting/stopping treatment
Is a brain scan necessary?
What’s a good care plan?
Dementia in care homes: EOLC, ACP
Prospects for prevention
[email protected]
07900 715549
@ABurns1907
Dementia Data
Harmonisation
Dr Jill Rasmussen/Joanna Gavins
Dementia Data Harmonisation
Diagnosis Rates KSS
• Sept 2014: 48%
• March 2015: 55.3%
• Aug 2015: 61.4%
National Rates
• Mar 2015: 61.6%
• Aug 2015: 66.2%
Improvement:
• Sept 14 to Mar 15 was 7%
• April 15 to Aug 15 was 6%
A further 5.2% improvement is needed by March 2016
Dementia Data Harmonisation
Dementia Data Harmonisation
Dementia Diagnosis Rate, Aug 2015 compared with Mar 2015
Dementia Data Harmonisation
Dementia Data Harmonisation
• CCG performance Aug 2015:
• Lowest High Weald Lewes Havens 54.4%
• Best Horsham and Mid-Sussex 67.1%
• Majority improving their position from 0.5% - 12.8%
• All CCGs have submitted their Dementia plans
with trajectory to meet the dementia ambition
by Mar 2016
• Most CCGs put in place contractual variance for
memory assessment services so ALL pts seen
and diagnosed within 12 wks
Dementia Data Harmonisation
Interpretation of practice level Data
Dementia Data Harmonisation
• Future baseline reports to be available in
Memory Assessment Services, Learning
Disability, Care Home Case Finding.
• Letter sent to Clinical leads and high impact
action plan requested to address position
• More confidence in achievement of standard
being attained following release of Aug 15 data
Dementia:
Quality Outcomes Framework
Dementia Recognition:
Data Searches
Dementia Subtypes
Dementia Recognition:
Data Searches
Codes Suggestive of Dementia
Dementia Recognition:
Data Searches
• Codes suggestive of dementia / Other codes
• Mild Cognitive Impairment
• Read Code Eu057; CTv3 code X00RS
• Local READ Codes used on EMIS LV
• EMISNQDD2, EMISNQDV1, EMISNQDD1,
EMISNQDD3
• Dementia Review - EMISNQDE1
• Other codes - EMISNQIM12
Dementia:
Recognition & Management
• We are doing better
BUT
• Can be improved
• Recognition of people at risk of and with
dementia is an ongoing process:
Needs to be embedded in every day practice
throughout health and social care if
Dementia Diagnosis Rates are to be
achieved and maintained
The Three“Cs”
Case Finding, Care
Homes and Care
Planning
Dr Jill Rasmussen
The Three “Cs”
• Case finding:
• Not just for GPs it is everyone’s responsibility
Dementia Recognition needs to be embedded in
everyday practice to maintain Dementia Registers
• Care Homes:
• Information often “hidden” in pt notes;
• Care Plans include
• Advanced Care Plans, Care Plans, End of Life Care
• ALL relevant Long-term condition reviews
• Templates in health, social care, third sector
MUST be holistic and Patient-centred
Dementia Recognition:
Not just the Primary Care !
Wider Team In the Community & Care Homes
• Community Team
• Community Matron
• District nurse
• Multidisciplinary team
• Incontinence, Falls
• Community Pharmacist
• Specialist nurses:
• Diabetic, Parkinson’s
• Care Home staff; residents’ families
• Intelligence from Community at large
Dementia Recognition
Case-finding
• Codes suggestive of dementia
• Memory Impairment, Mild Cognitive Impairment
• Old EMIS Codes:
• EMIS LV to EMIS web
• Medications used to treat dementias
• Specific populations:
• Learning Disability
• Delirium
Dementia Recognition
Case-finding
• Medications used to treat dementia – Alz Dis,
PDD
• Acetyl Cholinesterase inhibitors
• Donezepil (Aricept® , Aricept Evess®)
• Galantamine (Reminyl®, Reminyl® XL)
• Rivastigmine (Exelon®);
• Memantine hydrochloride (Ebixa® )
• Not just CURRENT use; EVER used
Dementia Recognition
Case-finding
• Outcome of referrals to Memory Clinic
• Diagnosis hidden in the text
• Also remember referrals to:
• Neurologist – younger / atypical
• Geriatrician – co-morbidities
• Learning Disability services
• Downs syndrome:
• Dementia onset 35 yrs; 50% have dementia at 60 yrs
• New residents in Nursing Home
Patient Review the Wider Team
LT conditions Reviews – QoF
• Pt centred review for ALL LT conditions in practice
Care Homes
• Responsible for arranging bloods, appts with
Practice Nurse / DN / Specialist nurse to visit home
• Pt reviews:
• GP session with Care Home Manager
• Review bloods, vital signs, meds, issues
• Separate session(s) visit to home for pt face-to-face review
Patient Review - Care Homes
Care Plans
• One disease OR Holistic i.e. All LT conditions
• For Health and Social Care?
• Not JUST:
• DNAR discussion
• Advance Statement
• Advance Decision
• Advance Care Plan,
• End of Life Care Plan
Care Plans: Why, What, When?
• To ensure care is:
• Fully integrated, of high quality, patient-centred
• Issues / Needs:
• Much better coordination from commissioners, GPs, hospital staff, care
homes domiciliary carers, community, patient support and voluntary
sector in creation / delivery of ACPs
• Wider use
• Many different administrative forms / processes that can lead to
confusion about how to put ACP in place successfully
• Confusion over responsibility for introducing ACP conversations across
professional and organisational boundaries
•
Especially if care is given from several different professionals and
organisations in different parts of the care system
Ref : SE Coast Senate Advance Care Planning 2014
Care Plans: Why, What, When?
Improving Uptake of Care Plans
• All professionals providing care for patients need to be
clear and agree responsibility for having Care Plan
discussions across teams and organisations
• Education and training of healthcare professionals
needs to be implemented about the importance of, and
approach to, Care Plans (ACP and End-of-Life care)
• Awareness needs to be raised amongst the general
public, patient support organisations and the voluntary
sector about the benefits and how to confidently initiate
ACP discussions themselves
Ref : SE Coast Senate Advance Care Planning 2014
Advance Care Planning
Medico-legal considerations
Lasting Power of Attorney - Two Types
• Financial
• Appoints someone to make decisions about money e.g. paying
bills, managing bank account, selling property.
• Can be used while the person still has capacity to give
instructions to the Attorney AND when they are no longer able
to do so
• Health & Welfare
• Appoints someone to make decisions about everyday care and
future planning.
• It gives responsibility for making decisions about a person’s
treatment if they are taken into hospital, but only if they cannot
make those decisions themselves
The Three “Cs”
• Case finding:
• Not just for GPs it is everyone’s responsibility
Dementia Recognition needs to be embedded in
everyday practice to maintain Dementia Registers
• Care Homes:
• Information often “hidden” in pt notes;
• Care Plans include
• Advanced Care Plans, Care Plans, End of Life Care
• Templates in health, social care, third sector
MUST be holistic and Patient-centred
Questions and
Answers
Dr Jill Rasmussen
Tea break
3.05-3.30
Agenda
•
3.30-3.35 Introduction to Models of Care (Dr Jill Rasmussen - Chairperson)
•
3.35-3.45 North West Frailty Hubs (Sue Robertson)
•
3.45-3.55 East Surrey Care Homes LES (Hayley Bath and Dr Anita Raina)
•
3.55-4.05 Coastal West Sussex Dementia Diagnosis Rates (Dr Bikrum
Raychaudhuri)
•
4.05-4.15 Q & A
•
4.15-4.25 Dementia Care within an Acute Provider (Lucy Frost)
•
4.25-4.35 Dementia Template letter (Dr Jill Rasmussen)
•
4.35-4.45 GP led Primary Care led Memory Assessment Service (Dr Lindsay
Hadley)
•
4.50-5.15 Panel Discussions on Models of Care
•
5.15-5.30 Conclusions and Next Steps (Dr Jill Rasmussen)
Introduction to
Models of Care
Dr Jill Rasmussen (Chairperson)
Dementia Diagnosis Pathway
Models
Potential Options
• Specialist-only multidisciplinary diagnostic/research service
• Specialist one-stop-shop plus GP supported diagnosis
• CMHT nurse-led diagnostic service
• GP incentivised diagnosis with enhanced CMHT support
• GP incentivised diagnosis with specialist support
Models of Dementia Assessment
and Diagnosis:
Identifying good practice in
successful models of
assessment and diagnosis:
• A primary care managed service
with specialist care outreach Gnossall
• A specialist care managed service
with primary care delivery Northumberland
• An entirely specialist led service Rotherham
Ref: NHS England Models of Dementia Assessment and Diagnosis: Indicative Cost Review Sept 15
Models of Dementia Assessment
and Diagnosis: Conclusions
• Describes actual models of dementia assessment and diagnosis
that are currently being used successfully.
• Impossible to predict how these models would work under a
different set of circumstances
• practical support to commissioners
• A focus on indicative costs, BUT the quality elements and the
diverse needs of patients must be considered in service redesign
• Each of the three units represented here were driven by the need to
provide excellent, high quality care to the people they serve.
Their passion for making things better for patients and carers
comes across very clearly. We hope you recognise and are
inspired by it.
Ref: NHS England Models of Dementia Assessment and Diagnosis: Indicative Cost Review Sept 15
Dementia Pathway Models: Bristol
Current Position
• Developed by a Multi-Disciplinary team; includes:
•
GP’s, Commissioners, Memory Service, Meds Management team.
• Meds Management support crucial as work involved changing the
way practices prescribe.
o Templates developed to support transition.
• EMIS web templates developed to ensure consistency
• Practices paid to diagnose dementia based on cost of clinical time
to do work. Diagnosing dementia not part of GMS / PMS contract;
o Work previously delivered in secondary care.
• Enhanced reviews also funded (over & above QoF requirements.
Model encourages practice nurses to take the lead.
• GP and practice nurses attend dementia training each year
Ref:/wmscnsenate.nhs.uk/files/6014/1813/4100/
The_Bristol_Model_Dementia_Diagnosis_and_Care_in_Primary_Care.pdf
Dementia Pathway Models: Bristol
Key Learning Points
• Clinical leadership/ownership to drive changes
• Support from Medicines Management vital
• Requires a good level of buy in, support and time to deliver
changes – not a quick option
• Proper community support required along the pathway
• Training needs to be in place for primary care
• Services needed post diagnostic support so that people living with
dementia and GPs are clear of the benefits of diagnosis.
Ref:/wmscnsenate.nhs.uk/files/6014/1813/4100/
The_Bristol_Model_Dementia_Diagnosis_and_Care_in_Primary_Care.pdf
Dementia Pathway Models: Bristol
Dementia Wellbeing Service
• Commissioned in 2014 to support this work. It will:
o Shift dementia from predominantly secondary to primary care.
o Focus on prevention and care planning.
o Have extra capacity in the services.
o Provide on-going support with dementia navigators
o Support Primary Care to diagnose dementia
o Have a one stop memory clinic for complex dementias
Results (Mar 2015)
• 62% diagnosis rate (previously 38%); 5th best in England
• 80% of cases now diagnosed in Primary Care
• No delays for memory clinic due to capacity.
Ref:/wmscnsenate.nhs.uk/files/6014/1813/4100/
The_Bristol_Model_Dementia_Diagnosis_and_Care_in_Primary_Care.pdf
NHS Five Year Forward View:
Lessons from the United States developing
New Care Models
Background:
•
Managed care evolved into integrated delivery networks in the
1990s; focus on better coordination of care to improve quality &
contain costs.
Evaluation
•
Most networks failed to deliver savings because:
•
Poor information technology
• Ineffective coordination of care for pts with complex chr needs.
• Bolted together existing providers & processes rather than truly
integrating clinical care
Ref: BMJ 2015;350:h2005 doi: 10.1136/bmj.h2005
Prospects for the NHS in England
in the this parliament:
Investment & reform should be at the heart of
the new government’s programme
Prospects for improved productivity : To make progress,
•
Providers must do more to engage staff in improving productivity
AND
•
Politicians must be realistic about the time needed to show results.
•
Finding solutions depends on transforming how care is delivered.
o Fragmentation between providers is a major cause of
treatment delays and waste.
•
This requires the development of new models of care and the
removal of barriers to their implementation.
Ref: BMJ 2015;350:h2541 doi: 10.1136/bmj.h2541 (Published 11 May 2015
Golden Ticket –
High Weald and
Lewes
Dr Jill Rasmussen
North West
Frailty Hubs
Sue Robertson – Head of
Collaborative Programmes &
Partnership, NW Surrey CCG
Integrated Care
Model of Care for Frailty
North West Surrey
Locality Hubs
Sue Robertson
13th October 2015
Context – Integrated Care Programme & Locality Hubs
•
Part of the CCG’s Strategic Commissioning Plan
•
A major component is the design of a new Locality Hubs
model of care for frailty
•
Engagement sessions to seek input on the new model
•
First phase to be in Woking
•
Fully commissioned service launched by April 2017
60
Indicative high-level roadmap
14/15
15/16
March
March
16/17
March
17/18
Implementation Plan in development
Woking
Pilot Live
Woking
Thames Medical
3 Locality Hubs
(fully operational)
SASSE
Develop
Service
Specification
All Localities
Run Procurement
(Service fully
commissioned)
61
Context - drivers for change
• Ageing population, people living longer & more
people living with chronic conditions
• Cost & demand pressures
• Overreliance on hospitals & residential care
• Not enough focus on prevention & early
intervention
• Disconnect between social & medicalised care
• Fragmented delivery of services leading to
duplication & a lack of coordination
Fully aligned with recommendations
in the 5 Year Forward Review
• GPs as mainstay of the local care system –
wider Primary Care, delivered at scale
62
We started with a hypothesis…
~30%
of people in an acute bed at any one time never
needed an acute admission
~30%
of people in an acute bed are receiving no active
care & are waiting to be discharged
~30%
of people have challenges that are social and
rooted in isolation rather than medical needs
We have most (if not all) of the services
we need to provide best possible care for
our population
63
Our hypothesis led us to two key ambitions
Less pressure
on the acute
sector
Better outcomes
& quality of life
1) No one should be in
an acute bed because
they are frail
&
2) No one should
become frail if they can
be helped to stay well
Improved care
quality & patient
experience
Optimised
health & social
care resources
More costeffective and
better value care
64
Our vision statement for Locality Hubs is…
”To support older people with frailty
to live at home healthily, safely and
happily for as long as possible”
65
We’ve created 3 ‘frailty domains’ based on people’s needs
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
Examples of need
•
•
•
Mobility and stability
Nutrition and hydration
Continence
•
•
Dementia and rationality
Depression and anxiety
•
CV disease with
•
•
Respiratory Disease
Neurological Disorders
– Diabetes
– Atrial Fib. / CVD
– PVD
•
There are many definitions
of frailty (E.g. Edmonton
scale) and all capture
elements of physical,
mental and general
wellbeing
•
The system support
needed to help a given
patient will depend on the
degree of need, the
individual’s ability to cope
with their circumstances
and the degree of family /
friend support available
66
We’ve created 5 segments based on level of functional dependency
Managed
Transition
Independent
Managed
Transition
Adaptive
Managed
Transition
Assisted
Managed
Transition
Dependent
Departing
Locality Hubs will aim to move people to the left & prevent progression to the right
Segment
Independent
Adaptive
Assisted
Dependent
Departing
Managed
Transition
Characteristics
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Live independently
Do everyday tasks without support
Maintain a high level of wellbeing
Live independently
Struggle with everyday tasks
Carry out tasks by adapting e.g. walk-in showers
Do everyday tasks to live independently, but not to the same standard
Likely to be receiving episodic care
Unable to live independently
Often need specialist care
Approaching end of life
Require palliative care
Involved in proactively preparing for changes in dependency
Supported during planned and unplanned changes
67
Frailty domains cut across segments creating a ‘matrix of need’
Hub scope
Managed
Transition
Independent
Managed
Transition
Adaptive
Managed
Transition
Assisted
Managed
Transition
Dependent
Departing
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
68
These needs will be addressed by 7 service lines spanning each
domain & segment which together form part of a person’s care plan
Locality Hub
Independent
Adaptive
Assisted
Dependent
Departing
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
69
What does each service line mean?
“I do the things that
keep me well and I will
do them for theIndependent
long
term”
Frailty domains
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
Locality Hub
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
70
What does each service line mean?
“I get the tools I
need to keep me
Independent
mobile, enable
me
to function day to
Frailty domains
day & manage my
own health”
Mobility & Daily
Living
Cognition &
Mood
Physical
wellbeing
Locality Hub
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
71
What does each service line mean?
Locality Hub
Independent
“I have the regular
check-ups I need to
stay well & get
Frailtytreatment
domainsquickly
Mobility & Daily
when I need it”
Living
Cognition &
Mood
Physical
wellbeing
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
72
What does each service line mean?
Locality Hub
Independent
“I’m on the
medications that
best
suit me, I know
Frailty
domains
Mobility
& Daily
how
to use them
Living properly & I’m
reviewed regularly”
Cognition &
Mood
Physical
wellbeing
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
73
What does each service line mean?
Locality Hub
Independent
“I make best use of
the resources
around me & my
Frailty domains
are
Mobilitycarers
& Daily
supported
to help
Living
me”
Cognition &
Mood
“I feel supported in
my caring role and
Physical
get support to have a
wellbeing
life
outside caring”
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
74
What does each service line mean?
Locality Hub
Independent
Frailty domains
Mobility & Daily
“ILiving
feel happy & able
to cope with my
circumstances and I
Cognition &
know where to get
Mood
help when I need it”
Physical
wellbeing
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
75
What does each service line mean?
Locality Hub
Independent
Frailty domains
Mobility & Daily
Living
“I know what to do
when things change, &
Cognition
& Mood
the people
that know
me & my circumstances
are there to support
Physicalme”
wellbeing
Adaptive
Assisted
Dependent
Departing
Adherence & Persistence
u
v Adaptive Environment & Assistive Tech.
Medical Monitoring & Testing
w
Medication Management
x
y Carers, Family, Friends & Community Support
Emotional Resilience
z
Transitions
{
Each element to be addressed as part of care plan
76
We’ve quantified the target patient cohort by segment
Hub scope
Managed
Transition
Managed
Transition
Independent
Managed
Transition
Managed
Transition
Adaptive
Assisted
Dependent
~5k
~4.7k
~5.3k
Departing
=
~15k
Criteria used to estimate target population by segment
• >75 & identified by GPs as Frail using Edmonton Scale
• Identified as at risk from functional decline & avoidable admission e.g.
•
•
•
•
Advanced lung function and breathing problems
Progressive neurological problems, including Dementia
In-dwelling catheters
Advanced cardiac disease
• Includes:
•
•
Nursing & residential home residents
EoL
77
So what is a Locality Hub?
It’s a physical building providing an
integrated frailty service for people & their
carers with locality GP practices & services
operating in a network
78
Locality Hub – conceptual model (one-stop-shop)
A physical building next to a community hospital providing an integrated frailty service for
people & their carers with all locality GP practices and services operating in a network
X
Locality Hub
Assessment, Care Coordination & Care Planning
Place of residence
e.g.
• Home
• Nursing Home
• Residential Home
• Extra Care Housing
Self Care
Care packages
People are referred to the Hub
from local services based on
flags for high risk & formal
screening at GP surgeries
Transport
Hub out-reach
u
v
w
x
y
z
{
Adherence & Persistence
Adaptive Environment & Assistive Tech.
Hospital
Medical Monitoring & Testing
Medication Management
Carers, Family, Friends & Community Support
Emotional Resilience
Transitions
Support services
Diagnostics
Pharmacy
Hub out-reach into
hospital to proactively
pull people through the
urgent care system
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
79
Multi-disciplinary Team working
A multi-disciplinary team approach will be taken to managing people in the Hub
Locality Hub
District
Nurse
Community
Matron
MDT Lead – Hub GP / GPwSI
Social Care Community
Mental Health
Worker
Nurse
Pharmacist
Social Care Mental Health
Specialist
Specialist
Community
Geriatricians
Therapist
Care Navigators
Practice Nurse
Specialists
Nurses
Other specialists
as required
Person’s GP
(MDT attendees may flex depending on patient need)
80
Assessment, Care Coordination & Care Planning
Effective ongoing assessment, care coordination & care planning supports
the delivery & coordination of the 7 core service lines:
•Tiered common assessments performed by a ‘Trusted Assessor’ –
level/type of assessment based on risk & complexity – specialist input
maybe required for more complex cases
•Assessments will normally be carried out in the Hub – however housebound people will need to be assessed in their place of residence
•Named Case Manager - every person attending the Hub is assigned an
appropriate Case Manager from the MDT to be responsible for their care
plan
•Named Care-Navigator - every person attending the Hub is assigned a
Care Navigator to act as single point of contact
•Voluntary & Third Sectors to play a central role in delivering care
coordination in the Hub
81
Locality Hub – conceptual model (one-stop-shop)
A physical building next to a community hospital providing an integrated frailty service for
people & their carers with all locality GP practices and services operating in a network
X
Locality Hub
Assessment, Care Coordination & Care Planning
Place of residence
e.g.
• Home
• Nursing Home
• Residential Home
• Extra Care Housing
Self Care
Care packages
People are referred to the Hub
from local services based on
flags for high risk & formal
screening at GP surgeries
Transport
Hub out-reach
u
v
w
x
y
z
{
Adherence & Persistence
Adaptive Environment & Assistive Tech.
Hospital
Medical Monitoring & Testing
Medication Management
Carers, Family, Friends & Community Support
Emotional Resilience
Transitions
Support services
Diagnostics
Pharmacy
Hub out-reach into
hospital to proactively
pull people through the
urgent care system
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
82
u
Adherence & Persistence
“I do the things that keep me well and I will do them for the long term”
INTERVENTION
Coaching,
training &
education
Well-being
classes
EXAMPLE ACTIVITIES
•
Patient: nutrition, hydration, alcohol and smoking,
hygiene, catheter care, coaching, shared decision
support, patient rehab, manual handling advice
•
Carer: care plan understanding, available support
learning, best practice learning
•
Staff: technical training, shared decision making,
motivational interviewing
•
Exercise classes (mental / physical; regular / trial)
•
Meals (at the Locality Hub)
83
v
Adaptive Environment & Assistive Technology
“I get the tools I need to keep me mobile, enable me to function day to day
& manage my own health”
INTERVENTION
Electronic
Devices
EXAMPLE ACTIVITIES
•
•
•
Mobility
Aids
Home
Adaptions
Remote monitoring & access (BP, warfarin, lung function,
safety, CPAP, telecare, BAS, suction, movement pattern, eprescribing, e-carte
Reminder aids (text, email, phone call), pill dispensers
Sensory aids (e.g. hearing aid)
•
Walking aids, splints and supports, assistive devices for
ADL, other aids
•
Home assessments
•
Advice on home environment – safety checks
•
Bathing equipment, lifts, hoists, ramps etc.
•
Meal preparation support
84
w
Medical Monitoring & Testing
“I have the regular check-ups I need to stay well & get treatment quickly
when I need it”
INTERVENTION
EXAMPLE ACTIVITIES
Regular
Check-ups
•
•
•
GP led check-up
Nurse led check-up (Practice Nurse/Healthcare Assistant)
Pharmacist led check-up
Specialist
Consultation
•
CV, Respiratory, Neurological disorders, Geriatrician,
Psychiatry, Podiatry, other
•
•
•
•
•
Blood pressure & hypertension
Hearing
Gait
Visual Acuity
Memory
•
•
•
•
•
Continence
Skin Assessment
Bloods & Urine tests
Bladder screening
Spirometry
•
•
•
•
Catheter replacement
Stoma Care
Infusion treatment
Sigmoidoscopy
•
•
•
•
•
Endoscopy/Colonoscopy
Fluoroscopy
Pressure sore care
Epidural steroids
IV Care
Diagnostics
& Screening
Minor Elective
Procedures
85
x
Medication Management
“I’m on the medications that best suit me, I know how to use them
properly & I’m reviewed regularly”
INTERVENTION
Medication
Review
Dispensing
EXAMPLE ACTIVITIES
•
Review of drug portfolio, drug-disease interaction, side
effect and A/I barrier
•
Pharmacist supported chronic medication dispensing and
intravenous treatment
86
y
Carers, Family, Friends & Community Support
“I make best use of the resources around me & my carers are supported to help me”
“I feel supported in my caring role and get support to have a life outside caring”
INTERVENTION
Information &
signposting
EXAMPLE ACTIVITIES
•
•
•
•
•
Assessment for •
carer support
Carer support
& training
•
•
•
Local community centres and faith groups
Voluntary opportunities
Support to use Surrey Information Point
Neighbourhood schemes
Food banks etc.
Carers assessment and advice
Signpost to local carer groups and services
Practical care advice and training
Dementia café
87
z
Emotional Resilience
“I feel happy & able to cope with my circumstances & I know where to get
help when I need it”
INTERVENTION
Individual
Support
Group
Support
EXAMPLE ACTIVITIES
•
•
•
•
•
Named care Navigator
Telephone outreach
Befriending
Personal coaching – activation
Counselling
•
•
•
Meeting at the hub
Good neighbour schemes
Use of community centres
88
{
Transitions
“I know what to do when things change, & the people that know me & my
circumstances are there to support me”
INTERVENTION
Crisis
Management
Rapid
Response
Discharge to
Assess
EXAMPLE ACTIVITIES
•
Single point of contact
•
Immediate management of acute episode / exacerbation
•
•
•
•
2 hour response service
Same day response service
Wound management
Outpatient specialist consultation for new condition
•
Proactive in-reach into A&E and hospital to pull people
through the urgent care system
•
Rehabilitation
89
Locality Hub – conceptual model (one-stop-shop)
A physical building next to a community hospital providing an integrated frailty service for
people & their carers with all locality GP practices and services operating in a network
X
Locality Hub
Assessment, Care Coordination & Care Planning
Place of residence
e.g.
• Home
• Nursing Home
• Residential Home
• Extra Care Housing
Self Care
Care packages
People are referred to the Hub
from local services based on
flags for high risk & formal
screening at GP surgeries
Transport
Hub out-reach
u
v
w
x
y
z
{
Adherence & Persistence
Adaptive Environment & Assistive Tech.
Hospital
Medical Monitoring & Testing
Medication Management
Carers, Family, Friends & Community Support
Emotional Resilience
Transitions
Support services
Diagnostics
Pharmacy
Hub out-reach into
hospital to proactively
pull people through the
urgent care system
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
90
Support Services - Diagnostics & Pharmacy
Diagnostics
• Timely access to diagnostics is important
•
Bloods, x-ray & ultrasound on-site with rapid access to
other diagnostics off-site – e.g. slots at another
location and then straight back to Hub
Pharmacy
•
A Hub pharmacy service will be provided
91
Other Elements of Model
24/7 The Hub will operate 7 days per week
•Certain components will need 24x7 access – e.g. Crisis
Management & Rapid Response with access to care plans
(for other services, such as 111 and ambulance)
•Other services could be 8-8
•Bloods, x-ray & ultrasound on-site; rapid access to other
diagnostics off-site – e.g. slots at another location and then
straight back to Hub
•
A Hub pharmacy service will be provided
Transport
•The Hub will provide transport to enable people to attend
92
Dementia Pathway
• Dementia care is an integral aspect of the patient-centred
care the Hubs will provide.
• All patients will have an initial assessment which includes
the 4A test
• If appropriate, assessment for depression and anxiety,
with scope to refer to hub mental health practitioner
• Dementia pathway agreed by the Professional Reference
Group; this will run alongside any disease specific
pathway
• The pathway links services including CMHTOP (including
Memory Clinic), Adult Social Care, Dementia Navigators,
Movement Disorders Service/ Parkinson’s nurse, Care of
the Elderly Neurology Service and specific voluntary
organisations.
93
Locality Hub – conceptual model (one-stop-shop)
A physical building next to a community hospital providing an integrated frailty service for
people & their carers with all locality GP practices and services operating in a network
X
Locality Hub
Assessment, Care Coordination & Care Planning
Place of residence
e.g.
• Home
• Nursing Home
• Residential Home
• Extra Care Housing
Self Care
Care packages
People are referred to the Hub
from local services based on
flags for high risk & formal
screening at GP surgeries
Transport
Hub out-reach
u
v
w
x
y
z
{
Adherence & Persistence
Adaptive Environment & Assistive Tech.
Hospital
Medical Monitoring & Testing
Medication Management
Carers, Family, Friends & Community Support
Emotional Resilience
Transitions
Support services
Diagnostics
Pharmacy
Hub out-reach into
hospital to proactively
pull people through the
urgent care system
Locality Network: GP Practices, Community & Social Services, Mental Health, Borough Council & Voluntary Sector
94
East Surrey Care
Homes LES
Hayley Bath (Service Transformation
Lead ) and Dr Anita Raina (GP) – East
Surrey CCG
Care associated with the Recognition
and Management of Dementia
East Surrey CCG’s Care Home Local
Demand Management Scheme
96
Background
At any one time East Surrey CCG has approximately 2,000 residents
in Care Homes across its geographical area.
A Care Home Scheme was developed to look at a new model of GP
support to Care Homes across East Surrey CCG. The main areas this
considers are:
•
•
•
•
A practice linked to one or more specific care homes
An identified GP to lead on Care Home Liaison
The provision of regular planned visits at a specified time
Availability for regular review of patient medication with the
identified Pharmaceutical Advisor
97
Aims
The intention behind this local demand management scheme is that it will
provide:
Individual assessment of all new nursing home residents within two weeks of
arrival, to include:
a)
b)
c)
d)
Care review
Medication review
Advance care plan
Decision on resuscitation status
A six monthly meeting with nursing home staff to:
a) Review all registered residents with respect to:
i.
Medication
ii.
Advance Care Plan
iii.
Resuscitation status
98
Care Homes
Challenges for GPs (Quest for Quality 2011 BGS)
• 61% of GPs found current arrangements for medical care
of patients in care homes unsatisfactory
• 68% of GPs - care homes major source of stress for GPs
• 73% of GPs - Lack of support or resources to manage
patients in care homes safely
99
Geriatricians
•
•
•
•
•
•
40% - medical support for care homes below average or poor
> 70% - depression and dementia not optimally managed
> 50% - End of life care could be better managed
73% - wanted greater involvement in care home work
Locally - significant numbers of patients from care homes
dying inappropriately in hospital within 24 hours of admission
100
Commissioned Care Home Matrons to
Support Care Homes
• Education
• Care Planning
• Focus on 999 calls - monitoring and assessing
appropriateness
101
GP - Locally Commissioned Service
• Review new patients within 2 weeks of admission to home
• Medication – e.g. polypharmacy, falls risk, iatrogenic
illness
• Past history
• Liaise with Care Homes - nutrition assessment (MUST
Tool), Falls Risk Assessment
• Care planning including end of life care where appropriate
- produce care plan with short summary of anticipatory
care
• DNAR forms
• 6 monthly review as above
102
Care Plan
• Involve wishes of patient and family and include Care
Home staff
• Visible to SECAmb, OOH (Share My Care), ? SASH, ?
community services, ??? Social Care
103
IBIS
• Data sharing agreement for SMC, IBIS
• ? SaSH, FCHC, St Catherine's Palliative Care Team
• Developed software to automatically transfer patient care
plan from primary care system to SMC and then to IBIS
• Medication out of date when plan written – aim to use
summary care record in the future
104
IBIS – Success!
Data for all patients at risk of admission
105
•
•
•
Reduction in inappropriate admissions and hospital
attendances
Reduced 999 calls - last quarter lowest ever figures for 5 years
Reduced A&E attendances - reduced calls and reduced
conveyances
Reduced A&E admissions
Admissions less than 24 hours halved
•
•
•
• BUT - reduction in admissions with high length of stay (4 - 30
days) but costs increased
• Initial investigation - appropriate for complex patients
106
Pharmacist in Care Homes
• Thorough review of medication - polypharmacy,
iatrogenic illness e.g. falls
• Waste - over ordering, discarded medication / sip feeds
107
Results
• 85% of patients dying in care homes as preferred place
of death
108
Unplanned Care - Care Homes
Scheme
One of the expected outcomes from the Care Home Scheme would be a reduction in acute hospital attendances as well
as a reduction in admissions.
The graph below shows that most Care Homes are having fewer A&E attendances when compared with 2013/14. Dr
Vijaykumar and Dr Hill have visited some of the homes concerned. Karen Devanny, Director of Quality & Nursing, is
leading a work programme to look at the issues around Care Homes to establish what the CCG could be doing to help
reduce A&E attendances.
109
Dementia Subtype Diagnosis
As part of the clinical review Jill Rasmussen has suggested
the inclusion of some Dementia Subtype Diagnosis that could
be used by a GP on a visit to a Care Home:
Diagnostic description
Read Code
CTv3 code
(e.g. EMIS systems)
(e.g. SystmOne)
Alzheimer’s Disease
Eu00z
F110.
Alzheimer’s Disease with early onset
F1100
X002x
Alzheimer’s Disease with late onset
F1101
X0030
Vascular dementia
Eu01z
XE1XS
Dementia in Parkinson’s disease
Eu023
Eu023
Fronto-temporal dementia
Eu02y
X0034
Lewy-body dementia
Eu025
XaKyY
Mixed dementia
Eu002
Eu002
Unspecified dementia
Eu02z
XE1Z6
110
Parity of Esteem - Dementia
Current performance for dementia case finding across East Surrey CCG as of March 2015 was 58.5%. Given the
estimated prevalence across the CCG to be 2,440 patients this means that an estimated 221 patients are still to be
diagnosed during 2015. Care Home residents provided a large number of this group.
As a CCG we have improved our prevalance of Dementia to nearly 58 % which is almost similar to the national one at 60
%. The target figure is 67 %.
East Surrey CCG
Practice
% Dementia Diagnosis Rate
Dementia
Ambition
Register
Gap
Sep-14ChangeOct-14 Change Nov-14 Change Dec-14 Change Jan-15 Change Feb-15 Change Mar-15 Change
Wayside Medical Practice
12
43
31
9.4%
9.4%
12.7%
18.8%
18.8%
18.7%
19.0%
South Park Surgery
11
22
11
22.2%
19.0%
21.9%
24.9%
28.0%
31.1%
34.9%
Woodlands Road Medical Centre
41
60
19
42.5%
42.5%
42.5%
42.4%
41.3%
45.7%
46.3%
Elizabeth House Medical Practice
37
51
14
40.2%
40.2%
40.2%
39.7%
39.7%
39.7%
49.7%
Pond Tail Surgery
56
72
16
35.8%
33.9%
38.5%
39.1%
38.2%
49.3%
51.9%
Smallfield Surgery
32
41
9
41.8%
46.8%
51.3%
54.0%
54.0%
54.0%
52.4%
Wall House
111
141
30
43.1%
44.1%
45.6%
46.2%
47.1%
49.5%
54.7%
Lingfield Surgery
108
128
20
40.1%
40.6%
51.4%
50.2%
53.9%
54.4%
56.2%
Hawthorns Surgery
86
99
13
44.3%
43.6%
44.4%
48.3%
55.1%
55.1%
58.5%
Warlingham Green Medical Practice
Moat House
Townhill Medical Practice
Caterham Valley Medical Practice
Birchwood Medical Practice
Oxted Health Centre
Whytleafe Surgery
Greystone House Surgery
Holmhurst Medical Centre
80
111
163
78
134
165
29
101
78
90
122
177
86
144
180
29
94
75
10
11
14
8
10
15
0
-7
-3
45.7%
64.0%
64.0%
45.4%
56.3%
55.6%
51.2%
59.3%
63.8%
46.4%
65.7%
62.5%
45.4%
61.6%
58.9%
51.2%
63.6%
63.8%
47.5%
66.1%
60.4%
56.6%
55.8%
58.6%
53.4%
63.0%
62.0%
45.4%
66.6%
61.7%
57.7%
56.8%
60.6%
50.8%
65.9%
63.5%
57.3%
67.7%
60.9%
57.0%
60.0%
59.5%
55.4%
71.7%
59.0%
57.3%
65.5%
61.7%
53.8%
62.8%
59.8%
57.7%
71.7%
64.4%
59.0%
59.8%
61.4%
62.1%
62.4%
62.5%
67.2%
72.1%
72.4%
East Surrey CCG
CCG Trajectory
CCG Gap
1433
1654
221
49.8%
50.9%
52.4%
53.4%
55.1%
56.3%
58.5%
49.8%
52.0%
54.0%
57.0%
60.0%
64.0%
67.0%
0.0%
-1.1%
-1.6%
-3.6%
-4.9%
-7.7%
-8.5%
111
Coastal West
Sussex Diagnosis
Rates
Dr Bikrum Raychaudhuri – Clinical
Dementia Lead and GP from Coastal
West Sussex CCG
Dr Bikram Raychaudhuri




https://www.primarycare.nhs.uk/default.aspx
S. of Eng 50.93 %
CWS
47.68%
Est. prevalence
◦ 9628

Dementia gap
◦ 5037




CWS DDR – 61.5%
Estimated prevalence (>65) = 8898
Estimated gap – 3422 people
Gap to achieve national ambition – 456

New enhanced service Dementia identification scheme



Data harmonisation - £7119 funding allocated to CWS


£55 / patient payment
Media / LMC controversies
£100 to each surgery to complete this work
QOF amendment – 2015 /2016

dementia domain to increase from 15 to 39 points from April 2015.





Series of supportive emails to all practices in
CWS
Discussion in locality meetings
IT support – search practice database and
identify patients using PRIMIS
SUS data cross referencing
Practice visit -14 surgeries with lowest
numbers (clinician + IT expert)
Pros




Impetus for team
approach
Engagement beyond
the ‘dementia’ team –
CCG / primary care
Focus on the ‘numbers’
Regional support – Jill
Rassmussen
Cons




£55 controversy
LMC contradictory
opinion
Winter pressures –
difficult for primary
care.
? Excessive /
conflicting demands






Care homes
Encourage greater diagnosis in primary care
Enhance post diagnostic support
Compare with secondary care (SPFT) data
Continue practice engagement
Continue CCG-wide team approach.
Questions and
Answers
Dr Jill Rasmussen
Dementia Care
within an Acute
Provider
Lucy Frost (Dementia Nurse
Consultant – Sussex Community NHS
Trust)
Key principles
• Understanding the needs of people with
dementia and carers
• Understanding the needs and concerns of
staff
• Education about dementia
• ‘Dementia is the concern of everyone’
• Leadership
Key achievements
• Set up and successful evaluation of Dementia
Clinical Nurse Specialist provision.
• Links with external partners and community
based support for people with dementia &
carers.
• Delivering a service in line with local and
national drivers (CQUIN etc) but thinking
differently about how we do this.
Supporting people with dementia
• Pre, during and post diagnosis
• Projects to link acute care with the
community
• Most importantly…….
• Involving the people with dementia and
carers being supported
• Shared care (Emerald and Poynings
Units)
Finding success in the unlikeliest of places
• A Tier 1 training initiative that took on a life
of its own.
• Music as a useful intervention that helps
people to feel good
http://wishingwellmusic.org.uk/film/
Going forward
• Taking excellent care for people with
dementia into community services across
Sussex
• An organisational strategy
• Robust pathways and sharing with
specialist dementia services.
• Doing what we know works well
Thank you for listening
• [email protected]
• Twitter: @lucyjmarsters
Dementia
Template Letter
Dr Jill Rasmussen
Template Letter – Why?
• Feedback from GPs that content of letters from
Memory Assessment Service do not state
clearly:
• The outcome of the review
• Diagnostic codes – ICD vs READ
• New medications
• Actions required from primary and secondary care
• Review of letters for resident’s of Care Homes:
• Issues, diagnoses unclear
Template Letter – Why?
Extracts from Letter to GP following review by CPN
• Miss W came to appt with her neighbour who has Power of
Attorney
• Retired teacher, two sisters died, never married. Father died of alcohol
poisoning, no FH memory problems
• Pt said she had no memory problems; was articulate & appropriate
• She was unable to complete the Addenbrookes Cognitive
Evaluation due to visual impairment
• She lives alone, daily carers, walks with a frame, meals on wheels
five times wkly, cleaner twice wkly, community alarm; friends visit
• Sleeps well, appetite fair, glass of sherry daily - ? more
• CT scan some cortical atrophy evidence of sub-cortical vascular
changes
Template Letter – Why?
Extracts from Letter to GP - Conclusion
• Result of review, CT scan and daily alcohol consumption discussed
with consultant
• CT scan results not described in letter
• Memory medication is not indicated
• Consultant:
• Tried to speak with pt on phone x 2 but unsuccessful
• CPN told to write to GP to say consultant had decided to discharge
Miss W from the Older People’s MH service
• What do you think about:
• The Decision
• The Diagnosis
Memory Assessment Service
Template Letter
• Does your MAS service
use a “template letter?
• Is it:
• Useful?
• Adequate?
Template Letter:
Other Useful Information
MMSE Scores:
• Mild Alz disease - MMSE 21–26
• Moderate Alz disease - MMSE 10–20
• Moderately Severe Alz disease - MMSE 10–14
• Severe Alz disease - MMSE <10
Template Letter:
Other Useful Information
Addenbrooke’s Cognitive Evaluation - III
(ACE- III) – replaced ACE-R
• Useful for MCI, differentiating dementia sub-types
• Brief cognitive test assesses 5 cognitive domains:
• Attention, memory, verbal fluency, language, visuospatial abilities.
• Total score 100; Takes 15 mins; cut off 82 to 88
• ACE-R cut off - 72
Mini-ACE (M-ACE): shorter version of the ACE-III
• Total score 30; takes 5 mins
Template Letter –
Other Useful Information
Neuroimaging
• NICE 2006: Structural imaging should be used to
exclude other cerebral pathologies and to help establish
the subtype diagnosis.
• Cortical or medial temporal lobe atrophy
• Sub-cortical vascular lesions
• Enlarged ventricles
Template Letter – Why?
• What information would you like to see in the
letter ?
• Diagnosis – ICD and READ
• Medications – changes / additions
• Actions
• Scores on key tests – MMSE, ACE-III
• CT / MR report
GP led Primary Care
Memory Assessment
Service
Dr Lindsay Hadley – Mental Health
Commissioning Lead Hastings and
Rother CCG
Dementia Diagnosis Strategic Commissioning
Event
13th October 2015
Lindsay Hadley
GP lead
Memory Assessment Service
Hastings and Rother
Eastbourne, Hailsham and
Seaford CCGs




Reduce the stigma associated with the diagnosis
of dementia
Encourage ease of access to care for people with
dementia and their families and carers
Change the culture in primary care from negative
and hopeless to pro-active and positive
Provide a more integrated service for people with
dementia



Could we manage dementia in the primary care
setting like other long term conditions?
Designed a Memory Assessment Service to run within
primary care using GPs and Practice nurses, GP
Premises, GP IT systems and practice staff.
In conjunction with Bradford School of Dementia
Studies drew up a validated Postgraduate certificate
for Practitioners with a special interest in dementia
that enabled GPs to deliver a safe service following
initial supervision by secondary care consultants in
neurology and psychiatry
INTEGRATION with a primary
care based service
Memory
assessment
service
Voluntary
sector
Residential
care
Secondary
care medical
Person with
dementia in
primary care
Secondary
care
psychiatry
Adult social
care
Dementia
advisors

100%
OPPMH Day Hospital Disinvestment 1/4/2012
25%
Dementia Therapies / Activities In-reach
Carers Respite Break
Functional Day Hospital Services – reprovision








25%
50%




input
Dementia Advisors Expansion
Balance for Memory Assessment Services (MAS)
to include
Primary Care / GP provided MAS
Imaging
10% of expected referrals requiring 2dary






For 18 months which then became 2 years we
piloted different models of MAS
A private contractor
SPFT
Primary Care led service
Each robustly evaluated against standards
and each other e.g. Time to diagnosis, time
spent with clinicians and qualitative data
around the patient and GP experience.






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Patients own GP suspects dementia and carries out a simple
screen e.g 6 CIT
Arranges CT scan and routine bloods and reviews
Refers to primary care led MAS
Specialist GP and nurse carry out assessments in the patients
surgery and input into the practice EPR
Patient and carer are informed of diagnosis and sources of
help. Targeted information is printed out for them.
GP and patient letter generated at the time through templates
– signed and sent
Follow up to make sure medication OK and care package in
place once or twice.
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Specialist GPs can liaise with secondary care both
neurology and psychiatry for help with
management or diagnosis
Dementia advisors (ASC/Alzheimers society) closely
linked and will see most patients within a few days
of diagnosis
Relationships with adult social care and the third
sector are good and the specialist GP is able to
discuss management options with them during
clinics
All is recorded in the electronic patient record so
continuity of care is preserved
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Appoint patients within 5 working days of
receipt of completed referral
Keep waiting times to a minimum - average
waiting time in H&R to 1st appt of 6 weeks
Appoint patients as close to their home
address as possible
Send a letter/management plan to GP after
every appointment with MAS (and to patient
where appropriate)
Provide single point of contact for patient
queries
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Significant increases in earlier referrals
Communications with GPs above average or
excellent
Patient respect and dignity above average or
excellent
Management plans considered to be above
average or excellent
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Local consultants both neurologists and
psychiatrists have acted as mentors for the
course – new relationships formed
GPswSI have sat in on clinics with them and
they have sat in on our clinics
Education afternoons for all practice staff
both clinical and non clinical staff in
protected learning time over 250 have
attended.
Dementia advisors, other voluntary sector
and ASC present
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Remote log-in means access to up-to date
electronic patient record with opportunities to look
at co-morbidity compliance etc
Opportunity to add to this in a timely manner
Can check contraindications/cautions with up-todate medication
Library of information documents and on-line
resources means tailored support can be printed
out at the time
Resources can be kept up to date.
Letters are generated through templates at the
time.
Panel
Discussions on
Models of Care
Dr Jill Rasmussen
Conclusions
and Next Steps
Dr Jill Rasmussen
Dementia Recognition and
Management – Resources
Dementia Recognition and
Management – Key Points
• Preventing well
• Diagnosing well
• Supporting well
• Living well
• Dying well
• Care Planning – DEMENTIA
• GP education – upskilling them
Thank you for
listening
Contact
[email protected]
[email protected]