PREVENTING ADMISSION TO HOSPITAL AND RESIDENTIAL CARE FOR PEOPLE WITH DEMENTIA David Shinegold Social Care Consultant Skills for Care Co-ordinator - Berkshire Tel:

SKILLS FOR CARE New Type of Worker Initiative The drivers for new social care roles include: User focused service design with staff able to provide more generic individualised services Improving strategic human resource and operational management of the workforce A reduction in the actual number of staff required to deliver services to a person using them A more skilled and independent high quality workforce able to manage services at the point of delivery A blurring of some long established demarcations between job roles.

The drivers particular to Bracknell Forest Borough Council were to make an impact on the following performance indicators: To increase the number of older people helped to live at home To decrease the number of admissions of people over 65 years to residential and nursing care To decrease the number of emergency admissions of older people to hospital

The Project Management Team consisted of stakeholders whose job roles contributed to the successful operation of the project BFBC Head of Long Term CareOverall management of the project BFBC Team Manager (Home Support) Co-ordinate development of the project BFBC Home Support ManagerManage the delivery of the service BFBC Care Co-ordinatorAdvise on referrals and levels of care BHC Trust Community Psychiatric Nurse Assessment of referrals Bracknell Alzheimers Society - chair Represent service users and undertake research BHC Trust PsychiatristAdvise on medical practice BFBC Human Resources Manager Facilitate changes to the terms and conditions of Support Workers BFBC Service CommissionerFacilitate changes to the way services were commissioned Skills for Care ContractorMonitor the project outcomes and disseminate information

In order to provide a cost effective domiciliary care service enabling people with dementia to remain in the community, the following areas were considered and addressed: The nature of the support that would be available to service users The structure within which the service would be provided and managed The terms and conditions under which support workers would be employed The training that would be available to support workers

As the project developed, it became clear that there was a considerable impact on: The relative-carers of service users Staff sickness and retention levels Implications for inter-agency collaboration The involvement of project stakeholders In-patient levels in the local hospital dementia ward

The nature of the support that would be available to service users Assessments would involve and represent the views of service users and relative-carers An Outcome Based* service would be provided based on Care Plans that focussed on outcomes rather than service levels Focus on improving and maintaining the relationship between the service user and their relative-carer A service user would receive consistent support from one main Support Worker *Social Policy Research Unit at the University of York

Examples of Outcomes for the service user which the Care Plan may include: Increased physical abilities Increased confidence or skills Improved mental health More social opportunities Have finances in order Essential physical needs met Quality of life maintained Cleaner/safer environment Changes in behaviour Risks reduced or removed

The structure within which the service would be provided and managed required Support Workers to have additional responsibilities to those normally undertaken by Domiciliary Care Workers which included: Encourage service users to regain lost skills Encourage participation in and transport service users to a variety of activities including shopping, day centres, outings, hospital appointments etc Offer personal support, advice and encouragement to service users and relative-carers Help service users maintain contact with family and friends Provide practical support and intimate personal care as well as household tasks to relieve some of the work carried out by relative-carers

Further tasks were required which were to raise the professional status of Support Workers Undertake specialist tasks under the supervision of professionally qualified team members Record information on Observation Sheets Submit written and verbal reports to the Community Psychiatric Nurse Take part in monitoring, reviewing, decision making and care planning

This led to modifying the Person Specification for Support Workers to include: Able to use initiative and deal with emergencies Organisational skills Recording and reporting skills Able to undertake and benefit from specialised training Stable Self reliant Stress tolerant

Raising the professional status of Support Workers was also achieved by: Employing workers on a salaried rather than an hourly paid basis Employing workers to work flexible hours at their own discretion Giving workers the autonomy to respond to situations as they found them Providing professional supervision both individually and as a team Providing professional training in dementia (UCL) Provide a structure enabling workers to communicate with one another, cover for each other’s absences and maintain continuity of care Provide opportunities to achieve NVQ at level 3 and above (compared with the normal expectation of domiciliary care workers achieving NVQ level 2).

Referrals to the Project Team took account of the following criteria: Diagnosis of dementia Known to local Mental Health team At risk of the home situation breaking down Reluctant or resistant to accepting traditional domiciliary care services

Referrals to the Dementia Team March 2005 – March months Total number of Service Users Discharged early from hospital Prevented from hospital admission Prevented from admission to residential/ nursing care Referrals not linked to imminent admission

The range of needs identified included: Dementia and alcohol abuse Forgetting to take medication Withdrawal of carer-relative due to change in work pattern Unable to maintain personal care/clean environment/ suitable diet/financial control Relative-carer unable to cope with increasing demands due to dementia Challenging behaviour due to dementia Weight loss

Number of Hours Support Received per Week from Dementia Team Service User Groups (Nos.) Max. No. of hours/wk support received Min. No. of hours/wk support received Average No. of hours/wk support received Prevented from admission to hospital care (4) (No. of weeks 100) Prevented from admission to residential or nursing care (15) (No. of weeks 364) Referrals not linked to imminent admission (14)

Financial Savings Over 13 months Hospital Care No. of Service Users No. of Weeks Cost per week in hospital Total Cost In hospital Cost per hour Dementia Team Total Cost of Dementia Team Average 9.25 hrs/wk Savings 4100£1,575£157,500£32.42£29,988£127,511

Financial Savings Over 13 months Residential/Nursing Home Care No. of Service Users No. of weeks Cost per week in Res. Or Nursing Home Care Total Cost in Res. or Nursing Home Cost per hour Dementia Team Total Cost of Dementia Team Average 7.55 hrs per week Savings 15364£450£163,800£32.42£89,096£74,704

Outcomes Significant to Service Users The areas of the service provided by the dementia team which elicited the highest satisfaction ratings were: Support Workers took account of my views Improvements in my emotional and mental health The help I receive fits in with my life and routine My relationship with my relative-carer has improved I feel that I have been treated with respect

Outcomes Significant to Relative-Carers I feel treated with respect The Support Worker takes account of my views when deciding what help to provide The Support Worker understands my individual needs and circumstances very well The Support Worker was very helpful in providing information about other services available 57% of relative-carers reported improvements in their general health 64% of relative-carers reported improvements in their emotional and mental health 85% of relative-carers felt that the help they received fitted in with their life and routine

A Selection of Comments from the Support Workers More time – not rushing with the service user Feel you have achieved things Building relationship with service user and relative-carer Intensive work I’m knackered! Good team rapport and trust Communicate with each other, management and relatives Knowledge of service user gives you more satisfaction Empowering – encouraging service user to regain skills in everyday activities Make phone calls in the evening to relatives Good understanding of team-mates’ work

MAJOR OUTCOMES AFTER 3 YEARS Hospital waiting list reduced to zero Dementia ward is now only 50% full All of the original support workers remain in post Only 2 weeks of genuine sick leave taken The Dementia Team is now a mainstream service and is to be tripled in size This model of service is to be extended to other areas – e.g. people with long term conditions The Dementia Team won the Skills for Care Accolades in 2007