1. Collaborative working in Dementia Care: Multiple disciplines, multiple teams, just one patient Dr Adam Gordon Consultant and Honorary Associate Professor Nottingham University Hospitals NHS Trust Honorary Secretary – British Geriatrics Society Email: adam.gordon@nottingham.ac.ukadam.gordon@nottingham.ac.uk adamgordon1978

2. INTERMEDIATE CARE COMMUNITY MATRON FALLS TEAMS COMMUNITY GERIATRICIAN CARE HOMES COMMUNITY STROKE REHAB COMMUNITY MENTAL HEALTH SOCIAL WORK GENERAL PRACTITIONER REABLEMENT TEAMS ACUTE HOSPITAL TEAMS RAPID ACCESS LIAISON PSYCHIATRY HOME CARE PROVIDERS Secondary Care Primary CareSocial Care

3. Comorbidity of 10 common conditions among UK primary care patients. Guthrie B et al. BMJ 2012;345:bmj.e6341 ©2012 by British Medical Journal Publishing Group

4. Body functions and structures ActivityParticipation Personal factors Environment

5. Body functions and structures ActivityParticipation Personal factors Environment Goal setting Encouragement Behaviour change Aids & appliances Adaptations Co-operation Assistance Legal Societal Rehabilitation therapies Treatment of “barriers” Information giving Skills training

6. Staff Interviews in Care Homes (STICH) Study 7 care home managers 7 care home managers 2 care home nurses 2 care home nurses 9 care home care assistants 9 care home care assistants 6 GPs 6 GPs 3 dementia outreach nurses 3 dementia outreach nurses 2 district nurses 2 district nurses 2 advance nurse practitioners 2 advance nurse practitioners 1 OT 1 OT

7. Common problems Older people are very complicated. Older people are very complicated. Trajectories are difficult to predict. Trajectories are difficult to predict. Don’t have the training. Don’t have the training. Resources are tight. Resources are tight. Regulation is always present. Regulation is always present. Roles and responsibilities aren’t clear. Roles and responsibilities aren’t clear. Communication is a problem. Communication is a problem.

8. Important observation Care home managers are pivotal. Care home managers are pivotal. Relationships between GPs and care home managers are pivotal. Relationships between GPs and care home managers are pivotal.

9. Identified responses Regulate (stick) Regulate (stick) Remunerate (carrot) Remunerate (carrot) Parachute in troops Parachute in troops The social movement model. The social movement model.

10. Mechanistic solutions – the “LES” Comprehensive assessment at the point of admission. Comprehensive assessment at the point of admission. Regular contact with home (at least two weekly). Regular contact with home (at least two weekly). Regular review of resident (at least 6 monthly). Regular review of resident (at least 6 monthly). 1:1 relationships GP:care home. 1:1 relationships GP:care home.

11. Necessary but not sufficient 1:1 relationship Trusting relationship with mutual respect “I wouldn’t wish our GP/care home on my worst enemy”

15. Physical Mental/Psych ological Functional Social Environmental CGA

16. Assessment Stratified problem list Bespoke Management Plan Goals

17. What is the evidence base for Comprehensive Geriatric Assessment (CGA)? TypeMortality Living at home Readmission Physical function Cognitive function Institutional0.78(0.62-0.97)1.19(1.01-1.39)0.85(0.70-1.03)1.22(0.84-1.78)1.79(0.73-1.46) Non- institutional 0.91(0.77-1.07)1.26(1.10-1.44)0.89(0.78-1.01)0.99(0.77-1.27)1.03(0.73-1.46) Combined0.86(0.75-0.98)1.26(1.10-1.44)0.88(0.79-0.98)1.06(0.86-1.30)1.41(1.12-1.77) Stuck AE, Siu AL, Wieland GD, Rubenstein LZ, Adams J: Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993, 342:1032–1036.

19. Patients don’t recognise “health”, “social”, “primary”, “secondary”, “physical”, “mental” care. They just recognise care. Patient’s lives aren’t driven by diagnoses, they’re driven by problems. More holistic approaches to healthcare are required. CGA is a holistic approach – but still healthcare dominant. Relationship-centred care, with patient and carers in the middle has to be the ultimate goal.