NELFT - pioneering improvements in dementia care Professor Martin Orrell North East London Foundation Trust and University College London

2000 – Havering dementia services – good practice (Audit Commission)

2003 – Cognitive Stimulation Therapy improves memory & quality of life

2008 – Memory Services standards piloted in Havering

2009 – Admiral Nurses in all boroughs

2009 – Havering HTT reduces bed use for Older People

2010 – Changing practice reduces admissions (HSJ 2010)

2011 – Collaborative Care Team reduces DGH bed use saves £1 million/year

2012 – NELFT/UCLP £290,000 funding for dementia training in DGHs

NICE-SCIE guidance (2006) www.nice.org.uk People with mild/moderate dementia of all

types should be given the opportunity to participate in a structured group cognitive stimulation programme … provided by workers with training and supervision … irrespective of any anti-dementia drug received …’

• n = 201 - 23 centres (18 care homes, 5 day care)

• A multicentre Randomised Controlled Trial (RCT)

• Significant improvement in cognition & quality of life• Cost effective (Knapp et al., 2006)

• Numbers needed to treat for cognition = 6• similar to dementia medication

Cognitive Stimulation Therapy (Spector et al., 2003)

Maintenance CST Trial – first results

236 participants (123 MCST/123 CST only)

After 6 months MCST Quality of life better

After 3 months MCST significant benefits Quality of life better (proxy)

Activities of Daily Living better

MMSE improved in MCST group 0.85 points

• Delivered by carer 2 times a week for 20-30 minutes

• 75 individual CST sessions

• 25 week programme

• Themed activities eg: Number Games

• Manuals and resource workbook

What is the Individual CST programme?

Positive outcomes for carers

The programme has given me more

tolerance

We’ve had some nice enjoyable times

doing the activities together

The programme has given me ideas I

never would have thought of

I feel like I have a purpose when

spending time with dad

I’m glad we have iCST, it has given us a

lot of help

It made us realise that parts of mum’s

memory work, and others don’t

It has taught us how to work on the things

that matter, and ignore the things that

don’t

I cannot say how much of a difference this has

made to my relationship with my

mother

CST work

• ADI World Alzheimer Report recommends CST

• Training evaluation part of the SHIELD programme

• Cochrane review support CST – Woods et al., 2012

CST website: www.cstdementia.com

Join the CST Network - email a.spector@ucl.ac.uk

UCLPartners - dementia streamImproving care in general hospitals

BEH + NMUT

NELFT + BHR

ELFT + BLT

CIFT + UCLH + RFH

Involving families/carers

Managing delirium

Education & training

Joined-up working

Step 1 Planning & consensus conference - June 2011

Step 2 Commitment - September 2011

Local leadership groups - acute Trust lead

Commitment to select objectives to work with

Define time line, outcomes, actions

Step 3 Review progress - January 2012

5 acute trusts UCLH, RFH, NMUH, BHR, Newham present with discussion of progress & outcomes

£2 million saving, 1700 staff trained

Step 4 Review outcomes - June 2012

awarded £290,000 grant to increase training across UCLP/NELFT (Orrell/Lourenco)

Collaborative Care Team BHR Trust Dr Steve O’Connor & Caroline O’Haire

Investment from PCT £0.4 million/year

Queens admitted 30,000 people 65+ in 2010/11

June-Oct 2011 - 998 pts dementia admitted/recognised

Average 1.2 days less than previous year = 1198 fewer days

5 months saving = 1198 X £350 (bed day cost) = £419,300

1 year savings estimated = £1 million

Havering - 40,700 over 65yrs

3400 with dementia

30% (1100) of those in care homes

Very low admission rates

Changing practice to reduce admissions for people with dementia Dr Afifa Qazi Havering Older People’s services

Bed Daysper 10,000 population

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Team A

Team B

Team C

Team D

Team E

Team F

Team G

Team H

Team I

Low bed base

Bed Occupancyper 10,000 population

0

2

4

6

8

10

12

14

16

Team A

Team B

Team C

Team D

Team E

Team F

Team G

Team H

Team I

RCPsych

Changing practice Close links GPs/practice nurses, care home, CMHTs

consultant mobile number

Quick response (same day)

Talks/ training at surgeries/selected care homes

GP Face to face discussions (eg acute confusion)

At care homes able to identify difficulties before crisis (no admissions for 2 yrs)

CMHT joint visits, support, discussion

Clinic - emergency slots for patients in crisis

Frequent follow ups for acutely unwell patients (2-4 weekly)

Encourage patients to ring in case of problems (contact sheet with secretaries number)

Building on Innovative services with Prof Burns‘future of old age psychiatry’

Conclusion Bed occupancy - <10% of RCPsych bed numbers

Access - support

Training - development

Liaising - providing the missing link

1/3 of beds of other NELFT consultants

Changing practice: reduces admissions cost effective popular with CMHT, care homes and GPs adds to effects of home treatment services takes time for full effects

Memory Services National Accreditation Programme (MSNAP)

58 members 24 accredited

18 as excellent 30 in review stage

Prime Minister’s

Challenge on dementia

increase number of MSNAP accredited clinics promote research in clinics

Four main stages to the accreditation process:

Self review – 3 months

Peer review – 1 day visit

MSNAP Accreditation Advisory Committee (AAC) – RCPsych, BPS, RCN, Alz Soc, COT

Royal College of Psychiatrists’ Education, Training and Standards Committee (ETSC)

Improvements Increase in % referrals seen 4-6 weeks

Reduction in % staff lack of training funding

Funding to open physical examination unit

Assigned a medical lead for the service

New information leaflets/packs developed for people with dementia and carers

Implementation of checklist for assessments

Possible reasons for improvement

The programme does not end after accreditation

Sophie Hodgeshodge@cru.rcpsych.ac.uk

020 7977 4971

www.rcpsych.ac.uk/memory-network

Memory Services Register is now live at www.rcpsych.ac.uk/memory-services-register

Dementia Strategy in NELFT

Stephanie Dawe - Chief Nurse & Executive Director of Mental Health 24 September NELFT AGM

Where we are – size of the challenge…

Borough Population 65+

Dementia %

Barking & Dagenham 21 227 1732 8

Havering 37 246 2807 8

Redbridge 31 483 2428 8

Waltham Forest 25 397 1895 7

ONEL total 115 353 8862 8

Locally (Outer North East London boroughs) prevalence data for adults >65yrs reported for 2009,** shows:

Locally, South West Essex the population of people >65yrs is approx 63,544 of whom 4,458 (14%) have dementia***.

Currently across NELFT there are varying levels of work/engagement, this varies by business unit and also by borough, much of this relates to the historic levels of investment in dementia services

Nationally, there are approx 700,000 people in the UK with dementia. Expected to double in the next thirty years to 1.4 million with the cost of services/care increasing to over £50billion a year*

*Source: DoH 2009**Source: Dr S O’Connor Assox medical director presentation 20.10.11***Source: GP data from ESSA)

Improve awareness - through knowledge transfer and training Earlier diagnosis and intervention - through robust pathways

across the system High quality care - through translation of research into action and training

continuing to improve…

The National Dementia Strategy (2009) outlined 17 objectives to achieve improvements in dementia care.

Transformation project aims to improve care in a number of key areas:

Achievements and next steps……..

Service transformation: Standardised screening tools Early detection and treatment Consistent delivery of Memory Services Integrated Community Treatment Teams with BHRUT End of life care pathways

Research & Development event later in year: Showcase dementia diagnosis and care Research into action.

Training: Train the trainer programme with Stirling University in progress Promotion: Website with materials available for sharing

DIST Team Structure (within Unplanned Care)

RGNBand 7

Support workerBand 3

RMNBand

6

RMNBand 7

RGNBand 6

Support WorkerBand 3

ADMIN

DIST Role within primary care

Assess and refer to appropriate services (i.e. CAS, memory service, social services & 3rd sector services , Community)

Provide short term intervention (6 weeks), monitoring and support and act on any increase risks

Work in collaboration with AAT (Admission Avoidance Team), Care Home Liaison Nurses, GPs, Community Teams ,OPMHT

Provide information and advice to PWD and their carers (i.e. medication and behaviour management and symptoms & UTI prevention)

Provide faster access to services and earlier diagnosis

DIST Role within secondary care

•Work alongside AAT, CCMT and social services to avoid inappropriate admissions and follow up in the community;

•Work alongside Clinical nurse Specialist, Complex Case Management Team and Social Services to reduce the length of stay in hospital;

•Promote and facilitate the use of intermediate care for people with dementia;

•Identify and review PWD or those experiencing memory problems and support in the community.

DIST Pathway

Referral to DIST via

•Community Services•GP’s•Ambulance Referral•AAT•Wards•3rd Sector•Individuals

• Memory Service• CMHT• Inpatient Services• MH & Community Hospital• Reablement• Social Services• Care Home• Liaison Team• ICT Services• 3rd Sector (Alzheimer’s, Befriending

etc.)

Referred to/

Follow-up by DISTup to 6 weeks

Outcomes

Number of referrals received 1154

Discharged from Hospital with DIST support 608

Seen in A&E / Amu (not admitted) including ambulance 402 referrals

Admission Avoidance Team referrals 77

GP referrals 77

Memory service requests forwarded 118 CAS request for CMHT input 41

Case Study 2

Patient ‘B’

Referred by GP, lives with husband, has carer 1 x daily. No formal diagnosis but experiencing memory problems. Becoming agitated, confused, aggressive, keeps pulling her catheter out (feels she does not need it) and at one time used scissors, hoarding tablets. Refused to go to A&E or hospital. Husband is burnt out.

What we did:-•Assessed and monitored risk and supported for 4 weeks;•Requested an urgent psychiatric review of medication;•Liaised with district nursing team to support with the catheter issue on a daily basis and worked closely with the team;•Liaised with social services for an increase in care package and future respite for her husband;•DIST referred to the memory service for further assessment;•Patient transferred to the mental health services after 4 weeks

Admission to hospital avoided

Referral DetailsReferral Details

Dementia Intensive Support TeamA&E DepartmentBasildon & Thurrock University Hospital (BTUH)NethermayneBasildon, Essex SS16 5NL

Tel: 01268 524900 Ext. 2873Fax: 01268 246895Email: dist@btuh.nhs.uk (for information only – not referral)

NELFT AGM Dementia within the Older Adults Care Pathway

Mental Health Services September 2012

Sarah Haspel Assistant Operational Director Dave Horne Operational Director

Steve O’Connor Assistant Medical Director

CONTENTS

Context

Existing provision

New care pathway

Building on Innovative services

The Context for Mental Health Services

National Dementia Strategy‘..specific provision needs to be made in terms of specialist community mental health teams and inpatient services for older people with mental disorder.

The separation of ‘organic’ and ‘functional’ disorders in terms of service provision is essentially a false dichotomy and one that is likely to disadvantage people with dementia with complex needs and their family carers.’

Short stories from Queens

Mr S - 72 years old

Mrs P – 68 years old

Present patient journey

Our new pathway – under consultation

Intention of care pathway for Older Adults and Cognitive Disorders - 5 key elements

1. Single point of access for all four boroughs

2. Standardisation of assessment processes

3. Management of all liaison services

4. Multi-disciplinary Community Clinics

5. Ability to define “care packages” for Mental Health Payment by Results

Building on Innovative services with Prof Burns

Young people with Dementia Specialist knowledge and skills

Cognitive disorders clinic

Specialist clinical nurses

Specific Support group

Research into Practice: SHIELDSupport at Home: Interventions to Enhance Life in Dementia £2 million, 5 Years, National Institute of Health Research

Maintenance Cognitive Stimulation Therapy (CST) groups - improve cognition & quality of life of people with dementia

Reminiscence groups - dementia SU & carers to maintain quality of life & improve relationships

Carer supporter programme - trains ex-carers to support new carers of people with dementia

Home treatment package - help to manage crises at home, reducing dementia hospital admissions

Training manuals - help other services approaches.   

Old Age Liaison pathway

Whipps Cross pilot and RAID 6 weeks pilot in Whipps Cross

Building on learning from Collaborative Care Team for OA Liaison in Queens

Modelling RAID from Birmingham – cross speciality service for mental health liaison with outreach

Impact Time to assessment General hospital staff confidence

Contacts

NELFT Mental Health Services

Sarah.Haspel@nelft.nhs.uk

David.Horne@nelft.nhs.uk

Stephen.O’connor@nelft.nhs.uk

Background slides

Another slide for CQUIN

Dementia and Mental Illnessin our 4 boroughs

From 2009 Population 65+

Dementia Depression Schizophrenia

Barking and Dagenham

21,227 36 1,732 3,184 212

Havering 37,246 57 2,807 5,587 372

Redbridge 31,483 57 2,428 4,722 315

Waltham Forest

25,397 48 1,895 3,809 254

ONEL Total 115,353 8,862 17,302 1,153

Percentage 7.7% (0.2%) 15% 1%

What we offer from NELFT Mental Health Services

Older Adult

Mental

Team

Memory Services

Including YPD

Admiral

Nurses

Day Services

Liaison Home Treat-ment Team

B & D Yes Yes Two Yes Queens Collaborative Care Team (CCT)

Yes

Redbridge Yes Yes Two Groups King Georges / WXH 2 nurses

Yes

Havering Yes Yes Two No Queens CCT Yes

Waltham Forest

Yes Yes One Yes Whipps Cross 1 nurse

No

Why Liaison…Dementia and Severe Mental Illness in Acute care Dementia: 42%>65 years admitted have dementia, 50%

undiagnosed, 3X more likely to die, 43% admissions avoidable (Sampson et al 2009)

Delirium: doubles Length of Stay (LOS) and halves chances of returning home successfully. 30 - 40% is preventable.

Depression: associated with increased LOS, mortality rates, health care costs and dependency. Low detection rates

Solutions…. Liaison can improve outcomes (clinical, LOS, re-admission health, care utilisation) and refer to community services.

Interventionsfor those with Dementia in MHS

Assessment Diagnosis Medication Signposting Support

Cognitive Stimulation Therapy

Reality Orientation

Reminiscence

Eco Therapy

Mindfulness-based Cognitive Therapy

Anxiety Management

Mental Health Promotion

Admiral Nurses engagement with carers

Delivering Dept of Health commitment to reduce antipsychotic prescribing in Dementia…

Low bed base – too SMI?

Clinical Outcomes – is this too SMI?

Use for notes to presentpathway

Aim to increase time available for new assessments (increase diagnostic rates and reduce waiting times)

End to indefinite Memory Clinic follow-up by Psychiatrists

Specialist nurse-led follow-up clinic for those with ongoing needs

Discharge to GP where patient stable and carer agreeable

Acceptance of future re-referral as necessary Dementia has progressed to severe stage Consideration of stopping anti-dementia drug Assessment and management of behavioural / psychological

symptoms (BPSD)

New developments..Cognitive Stimulation Therapy Bringing NELFT research into our Mental Health Services

Development for CST in care homes via special funds from Redbridge commissioners