Dementia Management- Commissioning integrated Care Dr Dee Gallop-GP & Associate Clinical Director Lincolnshire Foundation Partnership Trust Colin Warren – Head of Commissioning Mental Health Services, South West Lincolnshire Clinical Commissioning Group 1

Acknowledgement  This presentation is supported by an honorarium from Lundbeck Pharmaceutical Company 2

Introduction  Dementia is a syndrome caused by several illnesses characterised by progressive functional decline in –  Memory  Reasoning  Communication skills  ability to carry out daily activities independently 3

Introduction contd.  Associated behavioural and psychological symptoms include;  Mood changes (often prodromal)  Depression  Psychosis  Aggression  Wandering 4

Demographics  Approximately 750,000 are known to have the condition in the UK – numbers are predicted to double in the next 30 years  Costs are estimated at £17 billion and rising to over £50 Billion by 2025  60,000 deaths a year are attributable to dementia  33% of all people with dementia live in care homes  66% of people living in care homes have dementia 5

Lincolnshire -estimated prevalence of Dementia  Add document text here 3 6

Drivers  Living Well with Dementia – The National Dementia Strategy  Quality Outcomes for People with Dementia  NICE – quality Standards for Dementia Care  NHS Operating Framework 2012/13 7

Residential Care Homes  No requirement for trained nurses  Staff to patient ratio is variable especially at night  Some companies have structured training programmes and activity co-ordinators  Changes in mental or physical health or development of BPSD often leads to unplanned admission to both general and mental health acute services  Loss of current placement can follow 8

Nursing Homes  Provide –  Long term care  Respite care  30 day reablement programmes  Daycare  Mix of trained and untrained staff in variable ratios  Often minimum required staff to patient ratio (variable)  Diverse skills and aptitudes  High staff turnover  Inconsistent links to other health and social care professionals e.g. GP support 9

Dementia and QIPP  Implementation of NDS through efficiency savings.  Quality – early diagnosis; better care in Acute Hospitals; review of discharge and readmission; support to care homes  Innovation; Joint working with Primary care, Acute hospitals, Mental Health Trusts and Social care.  Productivity – facilitating timely discharge could save £50 million nationally. Better management of patients in acute hospitals potential savings of £6 million. Reducing Antipsychotic medication potentially saves £55 million per annum, prevent 1800 deaths and 1620 CVA’s 10

Commissioning Support  Joint Health Commissioning Panel for Mental Health -In collaboration with RCP and RCGP have produced commissioning support guides for Clinical Commissioning Groups- Dementia guide will assist in delivery of the National Dementia Strategy  Alzheimer’s Society – report that many care homes do not provide the level of one to one person centered care that is required. External specialist support is also highly variable. 11

Lincolnshire Care Homes  Review of each cluster (pre CCG boundaries) of admissions to acute hospital from care homes (2010).  Top 10 homes identified in each area  Majority of patients were admitted  Most attended out of hours  Dementia/Alzheimers disease was the most common co-morbid condition at presentation12-22% of all cases.  41% of admission to older adults wards in Mental Health were from Care Homes ( ) 12

Lincolnshire Care Homes  Current initiatives – Workforce training and development “Making a Difference “  Telecare Project – My Amego  Survey of Antipsychotic prescriptions (2011)  Follow up audit 2012  Development of awareness and education programme  Workshops on intermediate care liaison service and development of reablement models 13

Lincolnshire Care Homes  All Clinical Commissioning Groups have initiated care home projects  The Bromhead charity Care Homes Project  SWL CCG Care homes review (Baker & Raybould)  Acute care pathway development 14

Lincolnshire Care Homes  Reablement workshops – held in each quadrant of the county with the aim of improving the liaison between acute mental health liaison services,the hospital care team and current intermediate care services both health and social care  Improving awareness of each service their roles and responsibilities and developing the processes to support seamless integrated patient care. 15

Lincolnshire Care Homes  Scoping of resource gaps, knowledge and skills  Establishing the baseline to inform performance frameworks and assist in evaluation of the changes  Linking across to the acute care pathway for dementia to inform development and delivery 16

Lincolnshire Care Homes  SWL CCG Project – reviewed Care homes in the cluster and determined that there were a number of main issues for unplanned admissions  Catheter care – usually replacement  Falls/fainting  Poor advice e.g. 999 call  UTI’s and other common infections  Lack of advanced care planning and crisis management  Palliative care is inconsistent  Heart failure and COPD 17

Lincolnshire Care Homes  SWL CCG Project – Proposed solutions  Care homes pathway  Single point of access  Mobile outreach team – assess in the community,  MDT to include –  ECP, Social Worker, Mental Health Intermediate Care, access to GP advice through own GP or Urgent Care Centre as appropriate  Advanced care planning 18

Lincolnshire Care Homes  SWL CCG Project – Proposed solutions  Regular health care reviews by GP  Take note of LTC management  Pharmacy reviews to support medication management  Improved liaison between care professionals to support admission avoidance and facilitate earlier discharge to usual place of residence.  New pathway goes live April

Lincolnshire Care Homes  In Summary – Care homes require professional support to develop advanced care plans  Crisis management should seek to address those issue that are amenable to care in the care home – Mobile outreach team (or equivalent)  Mental Health services should be engaged and integral to the service  The care homes workforce needs education and training to support people with Dementia – Making A Difference  Care pathways should offer integrated and seamless care 20

A Final Thought  We cant increase the years of life for our patients with dementia but we can increase the quality of life in those years 21

Questions?  Any Questions? 22