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									     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 …’
               Cognitive Stimulation Therapy
               (Spector et al., 2003)

• 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
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
 What is the Individual CST programme?


• 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
Positive outcomes for
carers
I’m glad we have iCST,      The programme has          The programme has
it has given us a lot of      given me ideas I           given me more
          help               never would have               tolerance
                                 thought of


It has taught us how to                                It made us realise that
   work on the things                                      parts of mum’s
that matter, and ignore                                  memory work, and
  the things that don’t                                     others don’t


   I feel like I have a    I cannot say how much      We’ve had some nice
     purpose when          of a difference this has   enjoyable times doing
  spending time with       made to my relationship    the activities together
            dad                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 stream
Improving care in general hospitals


     Involving            Managing       Education &   Joined-up
   families/carers        delirium         training     working


                             BEH + NMUT

                            CIFT + UCLH + RFH


                               ELFT + BLT

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

 Havering   - 40,700 over 65yrs

 3400 with   dementia

 30% (1100) of those in   care homes

 Very   low admission rates
Bed Days
per 10,000 population
2000
1800
                        Team A
1600
                        Team B
1400                    Team C
1200                    Team D
1000                    Team E
800                     Team F
600                     Team G
                        Team H
400
                        Team I
200
  0
Low bed base
Bed Occupancy
per 10,000 population
 16

 14                     Team A
                        Team B
 12
                        Team C
 10                     Team D
                        Team E
 8
                        Team F
 6                      Team G
 4                      Team H
                        Team I
 2                      RCPsych
 0
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

  Areas for improvement highlighted

      Peers suggest ways of improving these

           Service encouraged to create action
           plan to address areas for improvement

               Short and long term goals

                   Action plan revisited after 1 year
              Sophie Hodge
         shodge@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…
 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*

                                                    Locally, South West Essex the
 Locally (Outer North East London
                                                     population of people >65yrs is approx
  boroughs) prevalence data for adults
                                                     63,544 of whom 4,458 (14%) have
  >65yrs reported for 2009,** shows:
                                                     dementia***.
        Borough        Population   Dementia   %
                          65+                       Currently across NELFT there are
                                                     varying levels of work/engagement,
 Barking & Dagenham   21 227        1732       8     this varies by business unit and also by
 Havering             37 246        2807       8     borough, much of this relates to the
                                                     historic levels of investment in
 Redbridge            31 483        2428       8
                                                     dementia services
 Waltham Forest       25 397        1895       7
                                                      *Source: DoH 2009
 ONEL total           115 353       8862       8      **Source: Dr S O’Connor Assox medical director presentation 20.10.11
                                                      ***Source: GP data from ESSA)
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:



     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
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)


               RGN                    RMN
                         ADMIN
              Band 7                 Band 7



               RGN                    RMN
              Band 6                 Band 6



              Support                Support
              Worker                 worker
               Band 3                 Band 3
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;

•Identifyand review PWD or those experiencing memory problems and
support in the community.
DIST Pathway


 Referral to DIST via
                                            •   Memory Service
                                            •   CMHT
 •Community Services                        •   Inpatient Services
 •GP’s                                      •   MH & Community Hospital
 •Ambulance Referral    Referred to/        •   Reablement
 •AAT                                       •   Social Services
 •Wards                 Follow-up by DIST   •   Care Home
 •3rd Sector            up to 6 weeks       •   Liaison Team
 •Individuals                               •   ICT Services
                                            •   3rd Sector (Alzheimer’s, Befriending
                                                etc.)
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 Details


Dementia Intensive Support Team
A&E Department
Basildon & Thurrock University Hospital (BTUH)
Nethermayne
Basildon, Essex SS16 5NL

Tel: 01268 524900 Ext. 2873
Fax: 01268 246895
Email:   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: SHIELD
Support 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
 Buildingon 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 Illness
 in our 4 boroughs
From 2009     Population      Dementia      Depression   Schizophrenia
              65+
Barking and   21,227       36 1,732         3,184        212
Dagenham
Havering      37,246       57 2,807         5,587        372


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

Waltham       25,397       48 1,895         3,809        254
Forest
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    Memory      Admiral   Day        Liaison           Home
            Adult    Services              Services                     Treat-
                                 Nurses                                 ment
            Mental   Including                                          Team
                     YPD
            Team
B&D         Yes      Yes         Two       Yes        Queens            Yes
                                                      Collaborative
                                                      Care Team (CCT)

Redbridge   Yes      Yes         Two       Groups     King Georges /    Yes
                                                      WXH 2 nurses

Havering    Yes      Yes         Two       No         Queens CCT        Yes
Waltham     Yes      Yes         One       Yes        Whipps Cross 1    No
Forest                                                nurse
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.

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

 Solutions…. Liaison canimprove outcomes (clinical, LOS, re-
 admission health, care utilisation) and refer to community
 services.
Interventions
for those with Dementia in MHS
                     Cognitive Stimulation Therapy
   Assessment       Reality Orientation

   Diagnosis        Reminiscence

   Medication       Eco Therapy
                     Mindfulness-based Cognitive Therapy
   Signposting
                     Anxiety Management
   Support
                     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 present
                         pathway
 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 offuture 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

								
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