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The Scale of the problem. In UK >700,000 people diagnosed with dementiaIn South west 73,000 increasing to 102,000 by 2025(41%?)Only 1 in 3 get a diagnosis EVERMore people retire to the south west and their life expectancy is the highest in the countryNHS Devon will have the highest number of de
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1. National Dementia Strategy Objective 8 Improved Care in acute hospitals-how can we achieve this and save money!? Dr Nicholas John
Consultant Geriatrician
RUH Bath
2. The Scale of the problem In UK >700,000 people diagnosed with dementia
In South west 73,000 increasing to 102,000 by 2025(41%?)
Only 1 in 3 get a diagnosis EVER
More people retire to the south west and their life expectancy is the highest in the country
NHS Devon will have the highest number of dementia cases in the country by 2025
3. In Hospital ¼ of all beds occupied by patients over 65 with dementia
Higher rates of placement, mortality and morbidity and longer length of stay for all conditions
Lincs study showed 60% of patients with dementia in acute beds did not need to be there
NAO suggests these factors cost each acute hospital £6million per year
4. Is Bath special? BaNES and Wiltshire have about 1/3 cases on the QOF dementia and are in bottom 1/3 for “diagnosis gap” and Cognition enhancer prescription in the country
122 elderly care patients with “seasonal” outliers
MH liaison provided by MH nurses
7 Community hospitals over 4 PCT’s
5. The Bath Story so far Oct 2007 Bath area conference of Old Age Medicine and Psychiatry to identify areas for improvement
Jun 2008 CSIP case note audit of 34 dementia patients at RUH
July 2008 Multiagency workshop to develop action plan
Sept 2008 RUH dementia stakeholder group established
Feb 2009 Trust wide survey of cognitive impairment
June-July 2009 SW SHA dementia review of BaNES and Wiltshire
January 2010 Action Plan agreed to capitalise on progress so far and attempt to complete objectives of NDS
6. Initial case note review 2008 Early information gathering is vital
Environmental factors are contributing to problems
Staff education and awareness lacking
“Medicalisation” of decision making
No whole system working
Risk averse culture to discharge
7. Cognitive survey 2009 6 Wards with large elderly focus
34% had cognitive impairment
Average LOS 25.4 days (up to 98 in some cases)
Only 50% had any diagnoses
14% currently known to MH services
Only 34% had any test of cognition
Orthopaedic #NOF proforma had a 90% MTS completion rate
8. 2009 SHA dementia review Peer review
Baseline assessment
Good practice highlighted
Deficits identified
Advice re implementation of the NDS
Action plan developed with timeline
9. SHA review key findings Chief officers from acute trusts often absent
User feedback very negative particularly food and drink, staff awareness and frequent moves
Dementia not a corporate priority and mainly a care of the elderly issue
Discharge delays due to difficulties with social services, access to intermediate care, CHC screening and lack of MH input
MH Liaison services usually unidisciplinary
10. However…. Many examples of innovative practice
Liaison nurses in Cornwall inreaching into Care Homes to minimise acute transfer
“Life story” books
Rotation of AHP’s through MH and acute trusts
Clothing ID system (B&Poole)
Day ward for wanderers in Dorchester
GP Academy in Cornwall
11. Positive practice cont., PAINAD scoring system in Cornwall
Rehab units with dual trained RGN/RMN (Poole)
“Grab sheets” and “message in a bottle”
CHC screening and allocation without panel (B&Poole)
Dashboard bed management in Torbay
Dementia specific intermediate care
Bristol MH liaison team ?LOS by 3-4 days and saved £1million pa
12. SHA action plan 2009/10 7 priority areas:
Early intervention and diagnosis for all
Improved community personal support
Implementing New Deal for carers
Improved care in acute hospitals
Living well in care homes
Informed and effective work force
Joint commissioning for dementia
13. Financial constraints NAO report Jan 2010
NDS implementation cost £1.9 billion
Funding by efficiency savings only £500 million
£150 million new money not ringfenced and no responsibility to show how money spent
Dementia not in Operating Framework “Vital signs”
14. So an impossible task? Executive sign-up
NHS 2010-15 will be a time of belt tightening
PCT payments to acute trusts will change from April with emphasis on reducing excess bed days in the setting of no increase and some reduction in tariff
Trust boards need to see tackling dementia will reduce bed stays reducing outliers and allowing 18 week RTT targets and 4 hour waits to be met
Dementia steering groups with executive presence will facilitate these discussions
15. How to do it Information gathering
Early cognitive assessment allowing discharge process blocks to be identified early
Dementia care pathway with cognitive algorithm (BGS/RCPsych) so every one knows what they are doing-dementia website helpful
Carer involvement early
16. How to do it Partnership working
Meet your commissioners!
Consider CQUIN schemes for dementia eg participation in national dementia audit
Clinical involvement in World Class Commissioning is key to success
Identify the outcomes you both want and how to achieve them
17. How to do it Patient/carer involvement
National Operating Framework will increasingly require evidence of user involvement to reward acute trusts
Patient Experience Tracker is a very powerful tool
Use your local voluntary sector-they are desperate to be involved more
18. How to do it Mainstreaming dementia care
Dementia training needs to be mandatory for all acute trust staff with records kept of uptake of training
Engagement of non-elderly care staff challenging but ward based dementia champions and incentive backed trust dementia chartermarks are one way
19. How to do it Benchmarking and data
National dementia audit starts Mar 2010
DOH dementia portal has some dementia metrics available from south coast SHA
SHA “must-do’s”
Clinical dementia lead
Care pathway in situ and evaluated
OPMH liaison teams
Training all staff in dementia
20. How to do it Others locally developed might include:
LOS data for dementia and non dementia including subspecialty eg #NOF
Discharge destination
Anti-psychotic prescriptions
Ward moves
Nutritional assessments
DOLS/MCA/MHA assessments
Environmental surveys
Quality of information on wards
21. Summary Don’t despair!
Make dementia core business
Commissioning relationships are of increasing importance
User viewpoint will become an important lever
Get it right for dementia and everybody will benefit