INTEGRATED CARE PILOT

THE NEWQUAY DEMENTIA PROJECT

Fiona HendersonICP Project ManagerNewquay Dementia Pilot 12th April 2010

Newquay Practice Based Commissioning Locality Group

Dementia: The Position in Cornwall

• Prevalence:

– Expected prevalence – 7,623 (Source: National Comparators)

– March 2010 QOF Dementia Register – 3,476 (45%)

• Services

– Fragmented and difficult to navigate

– Care provided within Older People Services - no distinct “Dementia” focus

– Insufficient preventative care – too many unplanned crises

– No consistent or integrated pathway for coordinated care

• Isles of Scilly

– Limited community services, strain on community hospital

– Reliance on provision on the mainland

Changing beliefs

Dementia is a complex condition with overlapping physical, mental, health

and social needs

Dementia is a progressive and chronic long term

condition

The majority of dementia care can be provided within primary care

Dementia: The Commissioning Plan

• Joint Commissioning Plan 2008 for Cornwall & Isles of Scilly

– Health & Social Care

– In line with the National Dementia Strategy

– Developed through consultation with service user and carer expert reference groups

– To be delivered through the Dementia Steering Group

– Programme led by a jointly appointed Programme Manager

• Objectives:

– Improve access, coverage and completeness of services

– Increase capacity to assess, treat and support individuals and carers

– Secure better integration between primary, social and secondary care

Newquay Pilot: Project Objectives

HEALTHCENTRE

DALTONHOUSE

NQ PBC

Social Care Services

Specialist Older People’s

Mental Health Services

PCT Services

Care Homes

Other Providers

NARROW-CLIFF

Good quality integrated care tailored to the needs of the

individual with dementia

Fragmented Services across multiple service providers

Newquay Pilot: Project Objectives

• To achieve the key objectives within the Cornwall & Isles of Scilly Dementia Commissioning Plan:

– To provide joined up, seamless access to patient care

– To manage Dementia through integrated and preventative case management in primary care

– To create a virtual dementia team of key staff from Health and Social Care organisations anchored around GP Practices

– To develop a scaleable and replicable model for delivering integrated care for dementia

• If successful … to role the model out across the county

Newquay Pilot: The Model (1)

PUBLIC HEALTH

Prevention

Support from the Specialist Memory Team to all non-specialist health and social care

services and practitioners

Awareness

Recognition

DIAGNOSIS

Assessment

Diagnosis

QOF Registration

CASE MANAGEMENT

Tier 1: Menu of Intervention

Tier 2: Menu of Intervention

Tier 3: Menu of Intervention

Tier 4: Menu of Intervention

End of LifeTier 1

Low IntensityGPs/Memory Advisors

Tier 2Medium Intensity

Specialist Memory Nurses

Tier 3High Intensity

Community Matrons

Tier 1SpecialistTop Tier

Newquay Pilot: The Model (2)

• Dementia Liaison

– Regular contact, support, close working with non-specialist teams

– Health Checks to review key health issues annually

– Partnership working to review medication

• GP Led Memory Service

– Education to identify/support patients not requiring specialist referral

– Finding the undiagnosed through opportunistic screening

– GP assessment, diagnosis and prescribing where appropriate

– Strong links with the Specialist Community Team

Newquay Pilot: The Model (3)

• Case Management

– Coordinated post diagnosis care - from diagnosis to end of life

– Centre of a virtual team of health & social care service providers

– Shift in focus from crisis response to anticipatory care

– Simpler processes to cut across organisational boundaries

• The Virtual Team

– GPs

– Memory/Liaison Nurses

– Adult Care and Support (Care Coordinators; Social Workers)

– Community Health Services (Community Matrons/Nurses)

Newquay Pilot: Expected Benefits

• Awareness:

– Reduce the stigma and increase understanding within the community

• Diagnosis:

– Improve access to increase early diagnosis of dementia

• Access:

– Improve access to treatment for individuals and their carers, with support provided from diagnosis through to end of life

• Choice:

– Increase the range and quality of services for people with dementia and their carers – to improve quality of life and support independence

• Capacity:

– Create additional capacity through efficiency and productivity gains

Newquay Pilot: Progress to date

• Reconfigured Community Mental Health Team

• Increased number of patients registered and receiving support

– Anticipated prevalence: 361; Baseline (04/09): 136 (37%); 02/10: 221 (62%)

• Improved quality of care

– Provision of ongoing Cognitive Stimulation Therapy Groups

– Provision of Carer Support and Training

– Launch of a SWAPS Shared Lives Scheme

– Increased expertise in mainstream parts of the healthcare system

– Clear access - easier for the patient, carer and professionals to understand

– Crisis avoidance & End of life care planning

Newquay Pilot: The Challenges

• Implementing the new model of care within CMHT

– Resistance – staff concerns and energy to rise to the challenge

– Resource - capacity to manage the temporary bulge in workload

• Data and Information Systems

– Systems not geared to collect required data (eg. Delayed Discharges)

– System compatibility to enable shared access to information

• The impact of early diagnosis

– Do patients actually want an early diagnosis?

– Differentiating between MCI and Dementia