Camden Memory Service a new model Sep 2016 Dr Suzanne Joels Consultant Psychiatrist and Clinical Director SAMH

Dementia in Camden 1688* in Camden with dementia 1507 live in the community 181** live in a care home 1131/65.8 % have a diagnosis Aim for 1266 (75%) diagnosed *based on new calculations ** Camden Dementia Plan

Closing the gap(s) Memory service model is diagnosis dependent. National move away from not only increasing diagnosis rate but also providing good quality post-diagnostic support. Increasing body of evidence to suggest that CEIs are effective even in severe disease and if stopped lead to deterioration. As the condition progresses, it is harder to manage you own care – no clear pathway for BPSD. More likely to have co-morbid physical health problems.

Vision for Camden Memory service To provide an assessment service for people with dementia Initiation of medication Post diagnostic support from diagnosis to death for all diagnosis Tiered service depending on need Skilled interventions delivered by qualified staff (nursing/OT/psychology) to people with BPSD who do not meet CMHT threshold Closer links with GP practices to provide informal support and advice around dementia. Therapeutic intervention for carers

New Model Aim to diagnose 1266 people with dementia Review the person – not just the medication Estimated caseload of 1085 (exclude care homes)

Camden – 3 localities, North (13 Practices), South (16 practices), West (6 practices) Consultant lead Band6 Band 5 1-2 Band 4 Consultant lead Band6 Band 5 1-2 Band 4 Consultant lead Band6 Band 5 1-2 Band 4

Staff Band 4 Practitioners undertake majority of reviews and provide signposting, advice and support. Band 4 Assistant Psychologists to offer START to carers and CST. Band 5 Nurses to complete initial and 1st six months medication reviews, anti-psychotic reviews and provide advice and support Band 4s on any medication and health related queries. Band 6 Nurses to review and offer interventions to patients with BPSD and other complexities, lead in key areas (i.e. Advanced Care Planning). Band 6 Occupational Therapist to work purely in an OT specialist role. Band 3 Support Worker role to become more of a clinical administrative role to keep up with increasing demand on admin.

ASC OT 3rd sector Death Decline Regular review and signposting depending on need/risk Intensive episode of care (Band 6) Regular review depending on need/risk Post diagnosis review Decline Move out od area or to 24 hr care Psychology OT

Assessment Scored outcomes at assessment and review, indicating direction of travel a Maintaining physical and mental health b Maintaining home and tenancy c Planning for the future d Financial e Social Interaction and Relationships Not yet collecting this data

“Contact Indicator” Risk Stratification The tool is designed to ensure that those in contact with the DN service receive a consistently high level of service/ intervention that is based on need, risk and protective factors in place. Those service user who are at greatest risk of isolation, disengagement and breakdown will receive the most frequent and face-to-face contact. Service users who have substantial, robust networks of informal or statutory support services in place will have a proportionately reduced level of input 70% Green 30% amber 0% Red currently

Services/ Interventions These are practical and non clinical • lots of advice, lots of information, lots of answering question • Expertise about what services are out there, how to access • An understanding dementia, but with easy access to clinical experts • Domestic safety, maintaining benefits and home • Linking into other services Working with Carers Advanced care panning Ongoing single point of contact – (until death, care home or the CMHT)

Benefits Clear pathway from diagnosis to death Continuity of care Access to specialist support One point of contact