1. Transforming Dementia Care within Royal Cornwall Hospital Trusts Dr Fiona Boyd, Dementia Lead. Bev Chapman, PCT Lead Maggie Trevethan, Clinical Nurse Lead

2. Past,Present and Future Service development to date Ongoing projects Our vision

3. To date. Ongoing over 5 years Shared care philosophy Designated clinical lead Designated ward base Collaborative working

4. Long Term Condition Diagnosis Maintenance Complex Palliative

5. Dementia Mapping - Comparison figures 2006-2008 Bed base 588 nTD = 69 (11%) nDementia=57(10%) nDelerium=9(1%) Bed base 538 nTD=74(13%) nDementia=57(10%) nDelerium=17(3%)

6. Correlation between delay in discharge and those patients with cognitive impairment A direct positive correlation between delay in discharge and those patients with cognitive impairment who demonstrated evidence of disability. 2008

7. 66% of these patients are located within the Medical Directorate. 45% of all cognitively impaired patients in RCHT Eldercare setting 30% individuals - ‘bed-blocking’ whilst they awaited discharge from hospital to care home environments.

8. The RCHT Memory Service provides Diagnosis (with a front door service) Rapid access to investigations and assessments Designated ward with specialty trained staff Guidelines and Care Pathways Supervision & reduction in prescribing(sedation &antipsychotics) Patient and Carer support Improved Awareness and Education

9. Guidelines and Pathways Guidelines Dementia Acute Confusion Palliative Care Pain management Mental Capacity Anti-psychotic prescribing DOLS Pathways and other Behavioural Chart and assessment tools Cognitive assessment tools PAINAD Carers support Life story books Communication Alert scheme

10. Education and Awareness Local to RCHT: Training F1/2, GP AND Specialty registrars trainees PMS Mental Capacity DOLS ‘Lets respect’ -DoH Competency Training for Nursing staff and allied specialties Patient and Carers forum

11. Education and Awareness Regional: Annual Eldercare Good Practice Day 2004-07 Dementia Away Day 2006 Lets Respect RCH(CIPS-Plymouth 2007) Hospice Staff training 2008/09 Gp training day 2008/09 Community Matrons 2008/09 Dementia Academy 2009 Worried About Your Memory (Alzheimers Society 2008-9) BBC Radio Cornwall Phone-in (2008/09)

12. Education and Awareness National: RCN: The Journey End –approach to palliative care (Cardiff 2007) RCN :Lets Respect –Communication Alert System( Edinburgh 2009) National Palliative Care Conference (7 th ): Palliative care in Dementia (Glasgow 2008) Psychiatry & Mental Health –Communication Alert Scheme (Leeds 2009) RCN: –Communication Alert Scheme–(Edinburgh 2009)

13. OPMHG -Cornwall Participation in Developing Cornwall Strategy Regional Audit Other Related Activities

14. Joint PCT/RCHT Audit of Nursing Home Admissions Dr Fiona Boyd Bev Chapman Kylie Cook Maggie Trevethan

15. Aims Retrospective Audit Admissions involving NH Identify the appropriateness of the admission with a view to developing pathways to reduce admissions and facilitate more effective patient journey

16. Reference details: Audit number NHS Number:Care home: SexAgeTime of admission DOADODLOS Referral source: GP/ A& ESB GP yes/no Ward allocation(s):1 2 3 4 Reason for admission: Diagnosis (es)1 2 3 4 Prescribing issues: Yes /No If yes, comment: Nursing needs: Yes/No If yes: date of requestdate actionedReview date Delaying factors Place of discharge Possible alternatives to admission

17. Provisional Data Jan-March 2009 Total Number Admissions 91 Length of Stay 1421 bed days See by GP before admission 27 (30%) Required admission 10 (37% of reviews; n/11% ) Seen ‘Out of Hours’ 59%

18. Breakdown of Admission Types

19. ‘Other’ General breathlessness – fatigue/exhaustion/SOB (12%) Admission from CPT Step up care (4%)

20. Other important Findings Palliative 29 (32%) Treatment feasible in the Home 64 (70%)

21. What’s Next? Analyse all data and correlate results Clear patterns: End of Life Care Appropriateness of Admissions Links with Advanced Planning for End of Life Care & review of community care

22. Guidelines: Dementia Section 1Dementia Pathway Summary Section 2What To Do on Admission and Why. Section 3How to Manage Difficult Behaviours. Section 4Dementia Assessment Tools and Care Plans Section 5Discharge Planning and Who To Contact. Section 6Assessing Capacity. Section 7Contact List of Community Mental Health Teams Section 8Appendices of Assessment Tools and Care Plans

23. No Cognitive deficit identified: Chronic / Acute on Chronic / Acute Suspected Dementia History Examination Investigations Cognitive Assessment Identify and Treat reversible factors Contact Eldercare team for definite diagnosis Diagnosis Dementia Known Check who made diagnosis and date No Psychiatric input needed discharge as per medical needs Is deterioration rapid and unexplained? Does history include: Deteriorating cognition Challenging behaviour Complex discharge Yes No Yes Nurse in a Calm Quiet Environment Any psychiatric concerns? Risk to others / self? No Contact eldercare psychiatric liaison team via switchboard If unavailable contact on call mental health services on ext 1300 Consider using section 5(2) Mental Health Act if necessary Using monitoring tools (see section 4) and sedate as necessary Use sedation if necessary. Adjust dose according to body mass and renal function. Review daily. Only if severe distress or there is an immediate risk of harm to the person with dementia or to others. Yes For details of above flow chart see following page

24. 24 hour behavioural chart Time 24hrs Agitation/ Restlessness Violence/ Aggression Care Refusal Wandering Fall Pain Sleep Disturbance Settled

25. Guidelines : Pain > 50% of elderly suffer from painful conditions Pain control is frequently inadequate. Demographic shift –increase in elderly population The number of patients with dementia who will experience pain is likely to increase.

26. Patients with Dementia Experience communication difficulties Lack understanding Interpret and express their pain in ways

27. PAINAD

28. Guidelines: Palliative Understand the drivers to improving end of life care for those with dementia Identifying terminal phase care Practical measures (care pathways)

29. Key Aims: Determining whether someone is ‘end stage’ – using clinical diagnostic indicators and specialist support. Identifying the patients needs (physical, psychological, behavioural) Identifying and managing symptoms Support to carers and families.

30. Best Practices covering: Pain Assessment (reference to Pain Pathway) Airway toileting and respiratory symptoms Physical hygiene Nausea Mouth care Tissue viability Bowel care Pastoral & Spiritual support.

31. What on For 2010 Re-launch –Let’s Respect campaign in collaboration with ‘Worried About you Memory’ What’s Your Story- Life Story Books Education -Modular programme (In collaboration with Learning Development) Completion of RCHT Dementia Strategy and Business Plan

32. Our Vision Countywide Education Program (NVQ Training and diploma status – County Wide resource) Countywide Network Forum Link Nurses for Dementia –RCHT End of Life –advanced planning

33. In Summary There is excellent leadership and ownership in advocating for dementia care in RCHT allowing multidisciplinary assessments and shared care with the psychiatric liaison services. Continuous drive to improve quality of care

34. The Royal Cornwall Hospital People with passion and vision.