Newquay Dementia Pilot
-
Upload
rowanpurdy -
Category
Documents
-
view
121 -
download
2
description
Transcript of Newquay Dementia Pilot
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