Cornwall and Isles of Scilly Memory Assessment Service

Julie Green, Commissioning Manager, Older People and People with Long Term Conditions

Angie Turner Project Lead Cornwall Partnership Trust

17th November 2009

Commissioning Dementia Assessment and Diagnosis Services

Local Context

• Dementia a PCT/Council commissioning priority as determined by local needs analysis and epidemiological challenges before the National Dementia Strategy!

• Epidemiological Analysis: 8,213 vs Aug 08 Dementia Registers: 2,645

• Tools available to Commissioners:

– NICE Guidelines - Evidence-Based Instruction Manual (Implementation Guidance very helpful)

– World Class Commissioning – • Increasing numbers of people receiving a diagnosis set as World Class

Commissioning Outcome• Focus on ‘market segmentation’ and market management, with expert advice

from SHA Commissioned consultancy AT Kearney• Emphasis on involving patients and carers

Beyond ‘Older People’s Mental Health’ and towards integrated pathways for ‘PEOPLE with dementia’

Commissioning integrated pathways rather than organisations

Prevention

Awareness

Recognition

Assessment

Diagnosis

Case Mgmt

Unscheduled

End of LifeGood quality care

tailored to dementia

Simple pathways and overlapping services

Tiered Menu of Interventions

Tiered Menu of Interventions

Drivers for Change (Old Provision)

• No service specification• Bundled in with wide range of ‘Older People’s Mental Health

Services’ – i.e. the mix of functional and organic• Unclear provision for younger people• Established provision for people with learning disabilities, but not

integrated• Wide variation across county (access, waits and quality)• Some Memory Clinics• Little carer or service user involvement in design, delivery and

review of services• Lack of integration with ‘primary care’ and no flows of

communication back to Dementia Registers – absolutely essential

Developing a Service Specification

• Decision made to develop a service specification and ask existing specialist provider, Cornwall Partnership NHS Trust to reconfigure to meet standards and expectations set

• To be achieved within existing resources – a reframing and standardisation of existing service

• Would initially remain as a ‘block contract’, but with a view to developing an activity based tariff (most straightforward part of pathway to do this)

• Available to everyone with suspected dementia, irrespective of age, ethnic origin or social status, including people with Learning Disabilities

• The service would offer a choice of venues for assessment, including ‘Memory Clinics’, home assessments and assessments in care homes.

• Key principle – organise around GP practices as early on identified anticipated prevalence and numbers of people on register

• Would be required to work closely with GPs and upskill primary care to increase the amount of screening, assessment diagnosis that could eg take place here

Calculating Referral Demand

• For service planning, need to know how many referrals to expect a year

• Limited historical information – new referrals for dementia not previously recorded (remember just OPMH activity and included eg crisis referrals for ‘functionals’)

• Advice from local service was approximately 2000 assessments a year

• Non-learning disability referrals set as 23% of prevalence (i.e. 1864) assessments a year

• Learning Disability referrals set as 2% of prevalence (164 assessments a year)

Calculating Demand for Memory Clinics

• Clinics vs Home Assessments

• Need to balance the need for increasing throughput with realities of being a rural area with limited transport infrastructure

• Some concerns that clinic assessment lower quality than home assessment – but difficult to evidence.

• Decided to set expectation that 40% of total referrals could be seen in Memory Clinic, collect evidence for first year and then adjust if necessary

Determining Location of Memory Clinics

• Shift from being organised around the convenience of organisational bases and professionals to the convenience of patients and carers!

• Major Towns (Truro, Falmouth, Liskeard, Saltash, St.Austell, Newquay, Wadebridge, Bude, Bodmin, Camborne, Helston, Penzance, Redruth, Hayle, St.Ives, Looe, Callington)

• Easily accessible venues – close to public transport

• Non-stigmatising – preferably not associated with ‘Mental Health’

• Quality Check – would be vetted and signed off by panel of service users and carers

• Specifying locations very popular with patients, carers, the public, council and GPs and the media

Determining Frequency of Memory Clinics

•Less then 10 potential annual assessments in Memory Clinic = No Memory Clinic

•11 - 50 potential annual assessments in Memory Clinic = 0.5 Day Memory Clinic every two weeks

•51 - 94 potential annual assessments in Memory Clinic = 0.5 Day Memory Clinic every week

•95 - 149 potential annual assessments in Memory Clinic = 1 day Memory Clinic a week

•150 potential annual assessments in Memory Clinic = 1.5 day Memory Clinic a week

Other Quality Standards

- Enable self-referral for those who do not want to access GP first- Referral to appointment target wait of 20 days- Appointment to Diagnosis target wait 30 days- Pre-counselling (compare genetic counselling) – to evidence ‘informed

choice;- Post diagnosis counselling – working through and beyond the diagnosis.

Emphasis that there is rewarding and meaningful life after diagnosis, this is not a death sentence.

- Standard information pack (approved by panel of patients and carers)- Everyone assigned a key-worker (Case Manager), linked to GP practice to

support patient from diagnosis until end of life (Newquay model)- Patient / Carer Satisfaction results collated and published on service website- Requirement on new provider to deliver education, training and support to

primary care

Public Engagement

- Draft service specification sent out to wide range of stakeholders for feedback

- Summarised version sent to every member of Alzheimer’s Society in Cornwall for feedback – received some very encouraging hand-written letters of support and telephone calls.

Implementation and Monitoring

- Action plan for delivery set out in service specification

• 25% of Memory Clinics are established by July 09• 75% of Memory Clinics are established by Dec 09• 100% of Memory Clinics are established by Apr 10

• Additional Monthly Commissioner/Provider performance meetings established to monitor progress and delivery

• Information reports agreed (Section 20 of Spec)

Next steps for Commissioners

• Ensuring implementation • Agreeing quality standards when patients diagnosed

e.g. in Acute hospital (different provider) • Unlocking the finances – once established, should

have sufficient data to determine cost of average diagnosis, opening up possibilities of moving to a cost per case activity contract

• Developing a service specification for Case Management (i.e. post diagnosis)

The Providers Journey

• Where we started• The journey and who we met along the way• Some of Road Blocks• Where we have got to• Where we go next

Context

• Draft Commissioning strategy January 2009 based NICE guidelines

• Debate/Discussion. Pressure on Commissioner - Provider relationship

• March 09 Project Lead role• Inclusive style to facilitate service change and delivery

Where we started

• Each team offering memory assessment and diagnosis service

• Service delivered in different ways across the county• Different resource allocation• No standardisation of assessment• Specific details not captured on data system

The Journey

• Engagement with key individuals• Working on strengths and what could be achieved• Project Management Group• Broadening out involvement- Task groups• Standardise services

Task groups

• Right people Right Place• Venues• Assessment and Diagnosis Pathway• Referral Protocol• Scans• Drop in/Self Referral• Performance data• Booking system• Service Information • Post Diagnosis Counselling• Training Plan

Outcomes/Learning from task groups

• Care Pathway• Enhancing the Commissioning Specification• Venues and Partnership• Partnership• Supporting workforce change and development• Data collection

Where have we got to

• 18 out 20 clinics up and running rest scheduled within next 6 weeks

• Standardised practice across the services• Information on service on web site, service leaflets.

information packs• Process for feedback from individuals and carers• Raised Profile of Early Detection and Diagnosis • Increased reported morale of staff with focus on specialist

skills development• Increase in positive attitudes around Partnership working

Road Ahead

•The future-Case management•Capacity planning•Audit and research•Robust data collection and reporting

Getting it Right For People

Good End of Life Care

Good Acute CareSupport for Carers

Good Quality of Care in Care Homes

Good early Diagnosis, memory clinics and support

Intermediate Care/Rapid response/re-enablement etc

Support at home

Housing & Support and Telecare

Information and Advice to stay Independent

Contact Details

Angie TurnerProject Lead

Cornwall Partnership TrustTel: 01209 881803/1876

Email: angie.turner@cpt.cornwall.nhs.uk

Julie Green Julie Green, Commissioning Manager, Older People and People with Long Term Conditions

Tel: 01209 886585Email: julie.green@ciospct.cornwall.nhs.uk

www.dhcarenetworks.org.uk/dementia/topics/browse/commissioning/