nelft - pioneering improvements in dementia care professor martin orrell north east london...
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NELFT - pioneering improvements in dementia care Professor Martin Orrell North East London Foundation Trust and University College London
2000 – Havering dementia services – good practice (Audit Commission)
2003 – Cognitive Stimulation Therapy improves memory & quality of life
2008 – Memory Services standards piloted in Havering
2009 – Admiral Nurses in all boroughs
2009 – Havering HTT reduces bed use for Older People
2010 – Changing practice reduces admissions (HSJ 2010)
2011 – Collaborative Care Team reduces DGH bed use saves £1 million/year
2012 – NELFT/UCLP £290,000 funding for dementia training in DGHs
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NICE-SCIE guidance (2006) www.nice.org.uk People with mild/moderate dementia of all
types should be given the opportunity to participate in a structured group cognitive stimulation programme … provided by workers with training and supervision … irrespective of any anti-dementia drug received …’
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• n = 201 - 23 centres (18 care homes, 5 day care)
• A multicentre Randomised Controlled Trial (RCT)
• Significant improvement in cognition & quality of life• Cost effective (Knapp et al., 2006)
• Numbers needed to treat for cognition = 6• similar to dementia medication
Cognitive Stimulation Therapy (Spector et al., 2003)
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Maintenance CST Trial – first results
236 participants (123 MCST/123 CST only)
After 6 months MCST Quality of life better
After 3 months MCST significant benefits Quality of life better (proxy)
Activities of Daily Living better
MMSE improved in MCST group 0.85 points
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• Delivered by carer 2 times a week for 20-30 minutes
• 75 individual CST sessions
• 25 week programme
• Themed activities eg: Number Games
• Manuals and resource workbook
What is the Individual CST programme?
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Positive outcomes for carers
The programme has given me more
tolerance
We’ve had some nice enjoyable times
doing the activities together
The programme has given me ideas I
never would have thought of
I feel like I have a purpose when
spending time with dad
I’m glad we have iCST, it has given us a
lot of help
It made us realise that parts of mum’s
memory work, and others don’t
It has taught us how to work on the things
that matter, and ignore the things that
don’t
I cannot say how much of a difference this has
made to my relationship with my
mother
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CST work
• ADI World Alzheimer Report recommends CST
• Training evaluation part of the SHIELD programme
• Cochrane review support CST – Woods et al., 2012
CST website: www.cstdementia.com
Join the CST Network - email [email protected]
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UCLPartners - dementia streamImproving care in general hospitals
BEH + NMUT
NELFT + BHR
ELFT + BLT
CIFT + UCLH + RFH
Involving families/carers
Managing delirium
Education & training
Joined-up working
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Step 1 Planning & consensus conference - June 2011
Step 2 Commitment - September 2011
Local leadership groups - acute Trust lead
Commitment to select objectives to work with
Define time line, outcomes, actions
Step 3 Review progress - January 2012
5 acute trusts UCLH, RFH, NMUH, BHR, Newham present with discussion of progress & outcomes
£2 million saving, 1700 staff trained
Step 4 Review outcomes - June 2012
awarded £290,000 grant to increase training across UCLP/NELFT (Orrell/Lourenco)
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Collaborative Care Team BHR Trust Dr Steve O’Connor & Caroline O’Haire
Investment from PCT £0.4 million/year
Queens admitted 30,000 people 65+ in 2010/11
June-Oct 2011 - 998 pts dementia admitted/recognised
Average 1.2 days less than previous year = 1198 fewer days
5 months saving = 1198 X £350 (bed day cost) = £419,300
1 year savings estimated = £1 million
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Havering - 40,700 over 65yrs
3400 with dementia
30% (1100) of those in care homes
Very low admission rates
Changing practice to reduce admissions for people with dementia Dr Afifa Qazi Havering Older People’s services
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Bed Daysper 10,000 population
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team I
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Low bed base
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Bed Occupancyper 10,000 population
0
2
4
6
8
10
12
14
16
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team I
RCPsych
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Changing practice Close links GPs/practice nurses, care home, CMHTs
consultant mobile number
Quick response (same day)
Talks/ training at surgeries/selected care homes
GP Face to face discussions (eg acute confusion)
At care homes able to identify difficulties before crisis (no admissions for 2 yrs)
CMHT joint visits, support, discussion
Clinic - emergency slots for patients in crisis
Frequent follow ups for acutely unwell patients (2-4 weekly)
Encourage patients to ring in case of problems (contact sheet with secretaries number)
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Building on Innovative services with Prof Burns‘future of old age psychiatry’
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Conclusion Bed occupancy - <10% of RCPsych bed numbers
Access - support
Training - development
Liaising - providing the missing link
1/3 of beds of other NELFT consultants
Changing practice: reduces admissions cost effective popular with CMHT, care homes and GPs adds to effects of home treatment services takes time for full effects
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Memory Services National Accreditation Programme (MSNAP)
58 members 24 accredited
18 as excellent 30 in review stage
Prime Minister’s
Challenge on dementia
increase number of MSNAP accredited clinics promote research in clinics
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Four main stages to the accreditation process:
Self review – 3 months
Peer review – 1 day visit
MSNAP Accreditation Advisory Committee (AAC) – RCPsych, BPS, RCN, Alz Soc, COT
Royal College of Psychiatrists’ Education, Training and Standards Committee (ETSC)
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Improvements Increase in % referrals seen 4-6 weeks
Reduction in % staff lack of training funding
Funding to open physical examination unit
Assigned a medical lead for the service
New information leaflets/packs developed for people with dementia and carers
Implementation of checklist for assessments
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Possible reasons for improvement
The programme does not end after accreditation
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Sophie [email protected]
020 7977 4971
www.rcpsych.ac.uk/memory-network
Memory Services Register is now live at www.rcpsych.ac.uk/memory-services-register
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Dementia Strategy in NELFT
Stephanie Dawe - Chief Nurse & Executive Director of Mental Health 24 September NELFT AGM
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Where we are – size of the challenge…
Borough Population 65+
Dementia %
Barking & Dagenham 21 227 1732 8
Havering 37 246 2807 8
Redbridge 31 483 2428 8
Waltham Forest 25 397 1895 7
ONEL total 115 353 8862 8
Locally (Outer North East London boroughs) prevalence data for adults >65yrs reported for 2009,** shows:
Locally, South West Essex the population of people >65yrs is approx 63,544 of whom 4,458 (14%) have dementia***.
Currently across NELFT there are varying levels of work/engagement, this varies by business unit and also by borough, much of this relates to the historic levels of investment in dementia services
Nationally, there are approx 700,000 people in the UK with dementia. Expected to double in the next thirty years to 1.4 million with the cost of services/care increasing to over £50billion a year*
*Source: DoH 2009**Source: Dr S O’Connor Assox medical director presentation 20.10.11***Source: GP data from ESSA)
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Improve awareness - through knowledge transfer and training Earlier diagnosis and intervention - through robust pathways
across the system High quality care - through translation of research into action and training
continuing to improve…
The National Dementia Strategy (2009) outlined 17 objectives to achieve improvements in dementia care.
Transformation project aims to improve care in a number of key areas:
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Achievements and next steps……..
Service transformation: Standardised screening tools Early detection and treatment Consistent delivery of Memory Services Integrated Community Treatment Teams with BHRUT End of life care pathways
Research & Development event later in year: Showcase dementia diagnosis and care Research into action.
Training: Train the trainer programme with Stirling University in progress Promotion: Website with materials available for sharing
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DIST Team Structure (within Unplanned Care)
RGNBand 7
Support workerBand 3
RMNBand
6
RMNBand 7
RGNBand 6
Support WorkerBand 3
ADMIN
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DIST Role within primary care
Assess and refer to appropriate services (i.e. CAS, memory service, social services & 3rd sector services , Community)
Provide short term intervention (6 weeks), monitoring and support and act on any increase risks
Work in collaboration with AAT (Admission Avoidance Team), Care Home Liaison Nurses, GPs, Community Teams ,OPMHT
Provide information and advice to PWD and their carers (i.e. medication and behaviour management and symptoms & UTI prevention)
Provide faster access to services and earlier diagnosis
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DIST Role within secondary care
•Work alongside AAT, CCMT and social services to avoid inappropriate admissions and follow up in the community;
•Work alongside Clinical nurse Specialist, Complex Case Management Team and Social Services to reduce the length of stay in hospital;
•Promote and facilitate the use of intermediate care for people with dementia;
•Identify and review PWD or those experiencing memory problems and support in the community.
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DIST Pathway
Referral to DIST via
•Community Services•GP’s•Ambulance Referral•AAT•Wards•3rd Sector•Individuals
• Memory Service• CMHT• Inpatient Services• MH & Community Hospital• Reablement• Social Services• Care Home• Liaison Team• ICT Services• 3rd Sector (Alzheimer’s, Befriending
etc.)
Referred to/
Follow-up by DISTup to 6 weeks
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Outcomes
Number of referrals received 1154
Discharged from Hospital with DIST support 608
Seen in A&E / Amu (not admitted) including ambulance 402 referrals
Admission Avoidance Team referrals 77
GP referrals 77
Memory service requests forwarded 118 CAS request for CMHT input 41
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Case Study 2
Patient ‘B’
Referred by GP, lives with husband, has carer 1 x daily. No formal diagnosis but experiencing memory problems. Becoming agitated, confused, aggressive, keeps pulling her catheter out (feels she does not need it) and at one time used scissors, hoarding tablets. Refused to go to A&E or hospital. Husband is burnt out.
What we did:-•Assessed and monitored risk and supported for 4 weeks;•Requested an urgent psychiatric review of medication;•Liaised with district nursing team to support with the catheter issue on a daily basis and worked closely with the team;•Liaised with social services for an increase in care package and future respite for her husband;•DIST referred to the memory service for further assessment;•Patient transferred to the mental health services after 4 weeks
Admission to hospital avoided
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Referral DetailsReferral Details
Dementia Intensive Support TeamA&E DepartmentBasildon & Thurrock University Hospital (BTUH)NethermayneBasildon, Essex SS16 5NL
Tel: 01268 524900 Ext. 2873Fax: 01268 246895Email: [email protected] (for information only – not referral)
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NELFT AGM Dementia within the Older Adults Care Pathway
Mental Health Services September 2012
Sarah Haspel Assistant Operational Director Dave Horne Operational Director
Steve O’Connor Assistant Medical Director
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CONTENTS
Context
Existing provision
New care pathway
Building on Innovative services
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The Context for Mental Health Services
National Dementia Strategy‘..specific provision needs to be made in terms of specialist community mental health teams and inpatient services for older people with mental disorder.
The separation of ‘organic’ and ‘functional’ disorders in terms of service provision is essentially a false dichotomy and one that is likely to disadvantage people with dementia with complex needs and their family carers.’
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Short stories from Queens
Mr S - 72 years old
Mrs P – 68 years old
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Present patient journey
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Our new pathway – under consultation
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Intention of care pathway for Older Adults and Cognitive Disorders - 5 key elements
1. Single point of access for all four boroughs
2. Standardisation of assessment processes
3. Management of all liaison services
4. Multi-disciplinary Community Clinics
5. Ability to define “care packages” for Mental Health Payment by Results
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Building on Innovative services with Prof Burns
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Young people with Dementia Specialist knowledge and skills
Cognitive disorders clinic
Specialist clinical nurses
Specific Support group
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Research into Practice: SHIELDSupport at Home: Interventions to Enhance Life in Dementia £2 million, 5 Years, National Institute of Health Research
Maintenance Cognitive Stimulation Therapy (CST) groups - improve cognition & quality of life of people with dementia
Reminiscence groups - dementia SU & carers to maintain quality of life & improve relationships
Carer supporter programme - trains ex-carers to support new carers of people with dementia
Home treatment package - help to manage crises at home, reducing dementia hospital admissions
Training manuals - help other services approaches.
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Old Age Liaison pathway
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Whipps Cross pilot and RAID 6 weeks pilot in Whipps Cross
Building on learning from Collaborative Care Team for OA Liaison in Queens
Modelling RAID from Birmingham – cross speciality service for mental health liaison with outreach
Impact Time to assessment General hospital staff confidence
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Background slides
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Another slide for CQUIN
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Dementia and Mental Illnessin our 4 boroughs
From 2009 Population 65+
Dementia Depression Schizophrenia
Barking and Dagenham
21,227 36 1,732 3,184 212
Havering 37,246 57 2,807 5,587 372
Redbridge 31,483 57 2,428 4,722 315
Waltham Forest
25,397 48 1,895 3,809 254
ONEL Total 115,353 8,862 17,302 1,153
Percentage 7.7% (0.2%) 15% 1%
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What we offer from NELFT Mental Health Services
Older Adult
Mental
Team
Memory Services
Including YPD
Admiral
Nurses
Day Services
Liaison Home Treat-ment Team
B & D Yes Yes Two Yes Queens Collaborative Care Team (CCT)
Yes
Redbridge Yes Yes Two Groups King Georges / WXH 2 nurses
Yes
Havering Yes Yes Two No Queens CCT Yes
Waltham Forest
Yes Yes One Yes Whipps Cross 1 nurse
No
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Why Liaison…Dementia and Severe Mental Illness in Acute care Dementia: 42%>65 years admitted have dementia, 50%
undiagnosed, 3X more likely to die, 43% admissions avoidable (Sampson et al 2009)
Delirium: doubles Length of Stay (LOS) and halves chances of returning home successfully. 30 - 40% is preventable.
Depression: associated with increased LOS, mortality rates, health care costs and dependency. Low detection rates
Solutions…. Liaison can improve outcomes (clinical, LOS, re-admission health, care utilisation) and refer to community services.
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Interventionsfor those with Dementia in MHS
Assessment Diagnosis Medication Signposting Support
Cognitive Stimulation Therapy
Reality Orientation
Reminiscence
Eco Therapy
Mindfulness-based Cognitive Therapy
Anxiety Management
Mental Health Promotion
Admiral Nurses engagement with carers
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Delivering Dept of Health commitment to reduce antipsychotic prescribing in Dementia…
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Low bed base – too SMI?
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Clinical Outcomes – is this too SMI?
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Use for notes to presentpathway
Aim to increase time available for new assessments (increase diagnostic rates and reduce waiting times)
End to indefinite Memory Clinic follow-up by Psychiatrists
Specialist nurse-led follow-up clinic for those with ongoing needs
Discharge to GP where patient stable and carer agreeable
Acceptance of future re-referral as necessary Dementia has progressed to severe stage Consideration of stopping anti-dementia drug Assessment and management of behavioural / psychological
symptoms (BPSD)
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New developments..Cognitive Stimulation Therapy Bringing NELFT research into our Mental Health Services
Development for CST in care homes via special funds from Redbridge commissioners