Dementia Recognition & Management Tuesday 13 th October 2015 12. 30 to 5. 30 pm – 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 – 2 pm NETWORKING LUNCH • 2. 00 -2. 05 Introduction - Dr Caroline Jessel (Chairperson) • 2. 05 -2. 20 National Perspectives 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 confident my end treated with dignity and of life wishes will be 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
Alistair. burns@nhs. net 07900 715549 @ABurns 1907
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 Eu 057; CTv 3 code X 00 RS • Local READ Codes used on EMIS LV • EMISNQDD 2, EMISNQDV 1, EMISNQDD 1, EMISNQDD 3 • Dementia Review - EMISNQDE 1 • Other codes - EMISNQIM 12
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, 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 – Qo. F • 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, 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 Qo. F 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%); 5 th 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 1990 s; 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: h 2005 doi: 10. 1136/bmj. h 2005
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: h 2541 doi: 10. 1136/bmj. h 2541 (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 13 th 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 16/17 March 17/18 Implementation Plan in development Woking Pilot Live Woking Thames Medical 3 Locality Hubs (fully operational) SASSE Develop Service Specification Run Procurement All Localities (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 So what do we need to do differently? 63
Our hypothesis led us to two key ambitions 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 Less pressure on the acute sector 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 Examples of need • Mobility & Daily • • Living Mobility and stability Nutrition and hydration Continence Physical wellbeing Dementia and rationality Depression and anxiety • Cognition & Mood • • CV disease with • • • 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 Respiratory Disease Neurological Disorders – Diabetes – Atrial Fib. / CVD – PVD 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 the long Independent 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 treatment Frailty domains quickly 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, Frailty domains I know 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 carers are Mobility & 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 me” 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 76
We’ve quantified the target patient cohort by segment Hub scope Managed Transition Adaptive Assisted Dependent ~5 k Independent ~4. 7 k ~5. 3 k Departing = ~15 k 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 Eo. L 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 Place of residence e. g. • Home • Nursing Home • Residential Home • Extra Care Housing Self Care Transport Hub out-reach Care packages People are referred to the Hub from local services based on flags for high risk & formal screening at GP surgeries Assessment, Care Coordination & Care Planning 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 { Support services Diagnostics Pharmacy Hospital 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 / GPw. SI Social Care Community Mental Health Worker Nurse Pharmacist Social Care Mental Health 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 Place of residence e. g. • Home • Nursing Home • Residential Home • Extra Care Housing Self Care Transport Hub out-reach Care packages People are referred to the Hub from local services based on flags for high risk & formal screening at GP surgeries Assessment, Care Coordination & Care Planning 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 { Support services Diagnostics Pharmacy Hospital 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 EXAMPLE ACTIVITIES Well-being classes • 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 • Coaching, training & education 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 EXAMPLE ACTIVITIES Crisis Management • • Single point of contact Rapid Response • • 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 Discharge to Assess Immediate management of acute episode / exacerbation 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 Place of residence e. g. • Home • Nursing Home • Residential Home • Extra Care Housing Self Care Transport Hub out-reach Care packages People are referred to the Hub from local services based on flags for high risk & formal screening at GP surgeries Assessment, Care Coordination & Care Planning 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 { Support services Diagnostics Pharmacy Hospital 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 24 x 7 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 4 A 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 Place of residence e. g. • Home • Nursing Home • Residential Home • Extra Care Housing Self Care Transport Hub out-reach Care packages People are referred to the Hub from local services based on flags for high risk & formal screening at GP surgeries Assessment, Care Coordination & Care Planning 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 { Support services Diagnostics Pharmacy Hospital 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) Care review b) Medication review c) Advance care plan d) 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 • ? Sa. SH, 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 CTv 3 code (e. g. EMIS systems) (e. g. Systm. One) Alzheimer’s Disease Eu 00 z F 110. Alzheimer’s Disease with early onset F 1100 X 002 x Alzheimer’s Disease with late onset F 1101 X 0030 Vascular dementia Eu 01 z XE 1 XS Dementia in Parkinson’s disease Eu 023 Fronto-temporal dementia Eu 02 y X 0034 Lewy-body dementia Eu 025 Xa. Ky. Y Mixed dementia Eu 002 Unspecified dementia Eu 02 z XE 1 Z 6 110
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 %. 111
Coastal West Sussex Diagnosis Rates Dr Bikrum Raychaudhuri – Clinical Dementia Lead and GP from Coastal West Sussex CCG
Coastal West Sussex Dementia Diagnosis Rates (and the star chamber …. ) Dr Bikram Raychaudhuri
The DDR journey (September 2014) https: //www. primarycare. nhs. uk/default. aspx S. of Eng 50. 93 % CWS 47. 68% Est. prevalence ◦ 9628 Dementia gap ◦ 5037
The DDR journey (Aug. 2015) CWS DDR – 61. 5% Estimated prevalence (>65) = 8898 Estimated gap – 3422 people Gap to achieve national ambition – 456
Strategies – incentivisation 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.
Strategies – practice engagement 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)
Role of star chamber 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
Future strategy 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.
Thank you
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 • Lucy. frost 1@nhs. net • 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
A primary care led memory Assessment Service Dementia Diagnosis Strategic Commissioning Event 13 th October 2015
Who am I? Lindsay Hadley GP lead Memory Assessment Service Hastings and Rother Eastbourne, Hailsham and Seaford CCGs
What did we set out to do? 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
How? 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
Funding sources 100% 25% 50% input OPPMH Day Hospital Disinvestment 1/4/2012 Dementia Therapies / Activities In-reach Carers Respite Break Functional Day Hospital Services – reprovision Dementia Advisors Expansion Balance for Memory Assessment Services (MAS) to include Primary Care / GP provided MAS Imaging 10% of expected referrals requiring 2 dary
How we got started -The Pilot 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.
Primary care led service 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.
In the primary care led Service 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
Standards Appoint patients within 5 working days of receipt of completed referral Keep waiting times to a minimum - average waiting time in H&R to 1 st 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
Evaluation after 18 months 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
Building relationships Local consultants both neurologists and psychiatrists have acted as mentors for the course – new relationships formed GPsw. SI 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
Innovative use of IT 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.
Any Questions?
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 jill. rasmussen@nhs. net joanna. gavins@nhs. net
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