Integrated Care Pilot: An integrated dementia care pathway for Newquay Department of Health Site Assessment 18 February 2009

Introductions: Our Partnership Newquay Practice Based Commissioning Locality Group CommissioningProvision Service Users and Carers Service Users and Carers

Commissioning Context Dementia is a shared strategic priority Joint Strategic Needs Analysis Clinical Dementia Lead appointed Joint Commissioning Plan Service Improvement Programme World Class Commissioning Outcome 07/08 May 08 Jul 08 Newquay PBC Plan Aug 08 Oct 08 Time Newquay: Our Accelerator Site

Why Newquay Integrated Care Pilot?

We will deliver and add value Our commissioning and provider partnerships brings a –Culture of quality improvement Whole System Demonstrator Site First Wave Improving Access to Psychological Therapies Site Exceeded LAA stretch targets for older people –A history of trust between partner organisations –Experience and expertise in joint commissioning Section 75 Agreement for Adult Mental Health and working towards Learning Disabilities –Experience and expertise in integrated provision Adult Mental Health Services Integrated Therapies Service Integrated Rapid Access Teams

We will deliver and add value –Local leaders, including GPs and clinical leads who are supportive of integration –Personnel who are open to collaboration and innovation –A commitment to synergise communications and IT systems –A strong foundation for success – work already underway –Excellence in stakeholder engagement – Older People’s Forums

Newquay Dementia Services The case for change and integration

The community system Narrowcliff Health Centre Hunter Dalton House Health Centre Harper NQ PBC Social Care ServicesSpecialist Older People’s Mental Health Services PCT ServicesCare Homes Other Providers

The ideal community system Prevention Awareness Recognition Assessment Diagnosis Case Mgmt & Treatments Unscheduled (and out of hours) End of Life Good quality care tailored to dementia Simple pathways and overlapping services

The community system Narrowcliff Health Centre Hunter Dalton House Health Centre Harper NQ PBC Social Care ServicesCPT ServicesPCT ServicesCare Homes Awareness Recognition Assessment CMHT Functional /Organic Assessment Diagnosis Case Mgmt Crisis Response Focus on intensive and crisis Access Case Mgmt Crisis Response Short Term Long Term Carer Support District Nurses RATS Community Hospital Awareness Recognition Rapid Response Primary Care End of Life Comm Matrons Other Providers

Areas for improvement Make dementia ‘everybody’s business’ rather than “somebody else’s business” Focus on prevention – physical health check – vascular checks to prevent vascular events Improve awareness and recognition of dementia amongst GPs, health and social care professionals, including care homes Increase the number of people receiving an early diagnosis and an annual health check.

Areas for improvement Treat dementia as long-term condition and focus on case management and anticipatory care to –Prevent or defer care home admissions –Prevent of defer hospital admission (especially from care homes) –Reduce length of stay in care homes and community hospitals Invest in low-intensity ‘treatment and support options’ and make better use of existing options – e.g. Whole System Demonstrator Dementia Package Share specialist expertise with ‘mainstream’ parts of system – –e.g. managing behaviour which challenges –Reduce use of anti-psychotic medication Share mainstream expertise with ‘specialist’ parts of system – –e.g. pain management, Liverpool Care Pathway Gold Standard Framework End of Life care planning

What we did and early learning 1) Dementia Liaison Pilot –QOF Health-checks (Community & Care Homes) –3 month pilot in 12 care homes – led to commissioning of dementia liaison service –Partnership with pharmacists – medication reviews 2) GP Led Memory Clinic –Education – anticipation of Dementia Academy 27 th March –Opportunistic screening with flu jab –Recognition, assessment, diagnosing and prescribing –Pilot of Locally Enhanced Service 3) GP Based Case Manager –Bring in CPN to work alongside GP practices –CPT Specialist CPN providing post diagnosis care for all patients, including those with vascular dementias in a primary care setting –Shift from intensive and crisis response to preventative and anticipatory –Simpler systems and paperwork – releasing time to care –Part of virtual team – District Nurses, Community Matrons, Macmillan Nurses, Social Care (accessing social care budgets)

Early Benefits Increase in numbers on GP registers and receiving quality annual health checks

Early Benefits Assessment & Diagnosis Early identification of dementia (“memory problems” or cognitive decline) Normalisation of memory problems Care Quality Increased use of telecare (All GP practices signed up to Whole System Demonstrator pilot) Increased expertise in ‘mainstream’ parts of the healthcare system Easy for the patient, carer and other professionals to understand Crisis avoidance End of life care planning Benefits to System: Economic Increased capacity in other parts of the system – reduced referrals to CMHT, freeing resource for more case management Reduced hospital admissions Case Studies: Assertive Case Finding and the Benefits of early diagnosis

The vision : replicating and sustaining success on a larger scale

Social Care Primary Care Health Care Secondar y Care Because labels create barriers Integrated Dementia Provision Integrated care – A scaleable model –Organised around GP practices –Delivering all aspects of care from diagnosis until end of life for all ages, including people with a learning disability –A tiered system of case management that supports both the individual and carer access the right treatment and support at the right time –A flexible, responsive and person- centred care framework which will easily translate into personalised services and individual budgets –Starting in Newquay before rolling out across Cornwall Finding people, find them early and giving them the integrated care and support they need.

Tiered Case Management Consultant Community matrons Dementia Case Managers (CPN/District Nurse/Social Worker Co-ordination and ‘Doing’) Memory Support Workers

The measurable benefits Assessment & Diagnosis Quality of Care Economic Qualitative –Patient –Carer –Staff

Service User & Carer Involvement Older People’s Forums LINks Alzheimer Society ‘Discussion Groups’ Established Carer Groups Visit Memory Cafes Investment in a Expert Patient and Carer Reference Group Use of Advocacy and those with expert communication skills where necessary Ongoing communication – e.g. newsletters

Implementation Jan - Mar Apr – Jun Jul – Sep Oct - Dec Jan - Mar Apr – Jun Jul – Sep Oct - Dec Jan - Mar Apr – Jun Jul – Sep Oct - Dec Ongoing Integration of Commissioning & Delivery of Older People’s Mental Health Programme a 4b 4c 4d 5

Governance Arrangements Provider Steering Committee (To be est) GPs CPT DASC PCT New Project Lead Roll-out of plan Workforce IT and information Finance Project Support Data Analyst Benefits Tracking Programme Management Change Management Operational Project Group (Provision) PCT Commissioning DASC Commissioning PBC Older People’s Partnership Board OPMH Programme Steering Group Operational Project Group (Commissioning) OPMH Prog Mgr Patient & Carers

Conclusions We offer: –An outcome-focused pilot with the potential for county and national comparisons –Several unique models of integration –Measurable benefits across a number of domains –Cross-over benefits : Opportunity to show how integration can achieve the outcomes of the National Dementia Strategy, Carers Strategy and End of Life Strategy Integration is the best tool we have to meet our shared economic challenge of rising demand. –drive a sustainable shift in resources and culture towards early intervention, personalisation and improved outcomes for people with dementia and their carers. Integration is the only way to meet the complex and diverse needs of people with dementia Integrated services are more satisfying and rewarding places to work An integrated system frees us to deliver person-centred care