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Post Diagnosis Support. Emerging Themes in Glasgow

Post Diagnosis Support. Emerging Themes in Glasgow. Stephen Lithgow Dementia Support and Development Lead. GG&C NHS. 7 th March 2014. Webex Objectives. Discuss a working model of PDS. Consider a PDS pathway and delivery mechanisms. Identify strengths and weaknesses of a PDS model.

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Post Diagnosis Support. Emerging Themes in Glasgow

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  1. Post Diagnosis Support.Emerging Themes in Glasgow Stephen Lithgow Dementia Support and Development Lead. GG&C NHS. 7th March 2014.

  2. Webex Objectives • Discuss a working model of PDS. • Consider a PDS pathway and delivery mechanisms. • Identify strengths and weaknesses of a PDS model. • Explore common issues. • Problem solving.

  3. Overview • HEAT Target. • Glasgow South PDS. • Driver diagram. • Key Issues. • Discussion (Approx 30 mins).

  4. HEAT Target

  5. The HEAT Target “ To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a link worker, including the building of a person-centred support plan”.

  6. The HEAT Target • ‘Link worker’ - Could be 3rd sector link worker, mental heath staff, Social work or other worker who may deliver support for year. • Use 5 pillars approach. • Personal plan. • Must be trained to Enhanced Level of Promoting Excellence.

  7. 5 Pillars of Support • The new commitment informed by Alzheimer Scotland “5 pillar” model. • help to understand the illness and manage symptoms; • support to stay connected to the community; - peer support; - help with future decision-making; - and developing a personalized care plan for their future care.

  8. Glasgow South Sector

  9. Glasgow South Sector. • Population 220,000 (30,00 over 65). • Dementia Calculator 2646 prevalence (Eurocode). • 1403 on QoF. 53% of prevalence diagnosed HEAT target. • 327 Incidence. (New clients per year). • Require 6-7 W.T.E staff. • Based on caseload approx 50.

  10. Delivery Model NHS and 3rd Sector. • NHS/3rd Sector link workers. • CMHT (CPN/OT) staff and Alzheimer Scotland. • Based in 2 locations. Elderpark and Shawmill. • One additional Alzheimer Scotland worker in each team. • Change Fund.

  11. What happened. • 301 clients in first year. • Alzheimer Scotland link worked approx 100. • NHS (CPN) link worked 200. • Severity. At least 42% mod to severe. (20% unknown). • Caseloads max around 50.

  12. What happened. • Monthly data returns started. • Personal plan developed. Started using an outcomes approach. • Raised £371,000. • Piloted supported self management.

  13. Driver Diagram • Pathways to diagnosis and post diagnostic support are clear and understood. • Effective partnership governance of the delivery of the PDS Target. • Data capture and reporting systems in place. • Service Redesign Opportunities have been maximised. • Person centred care approach underpins delivery of all PDS services. (Outcomes).

  14. PDS Pathway. Example.

  15. Data Capture • Monthly returns. • Named person in each sector. • Shared drive for Health Board. • Link workers putting data on system. • Ongoing errors. • Co-morbidity. Relative need. • PDS Follow up. Longitudinal.

  16. Person Centred Care. • Outcomes and NHS staff. • NES and SSSC training. • Personal Plan. • Using Outcomes. Quantitative and qualitative recording.

  17. Partnership Governance • Alzheimer Scotland staff co-located in OPCMHT. • Honorary Contracts. • Access to Metaframe (NHS e-mail, PiMS, and shared drive). • Patient information. Need to know basis. Consent. • Overarching Health Board agreement.

  18. Service Redesign • Not like Dem Demonstrators. • ‘Minimal disruption’ approach. • Adding on resource to existing team and new skill mix. • Use existing health IT, buildings, resources.

  19. Some Key Issues

  20. Issue: Assessment & Allocation of Link Worker. • Diagnosis- Traditionally cognitive and some functional assessment. • Often more complex needs. • Indicator of Relative Need (IoRN). • Allocation. Complexity/need but how? • Less complex 3rd Sector. More complex Health. • But depends on existing team mix.

  21. Issue: Dementia Severity and Co-morbidity. • 35% early. • 39% clients moderate. • 4% severe. • Not known 22%. • Physical frailty and co-morbidity across PDS client group. • Light touch theory and often more complex More than 5 pillars. • ‘More 8 pillars....’

  22. Issue: Promoting Excellence • Should be at Enhanced Level. • Benchmarking still needs to be done. • Benchmarking tool for link workers? • Capture qualifications/training and work experiences. • PDS training. Outcomes training. • Sensory impairment.

  23. Issue: Link Worker Case Load. • Ceiling around 50. • Needs to consider complexity/workload with caseload weighting. • 3rd Sector clients should be less complex but not always. • Danger of overwhelming staff. Allocation & throughput important.

  24. Issue: Link worker role • Supporting more than 5 Pillars. • Complexity. Overlap with proposed 8 pillar/ongoing care. • Risk of taking on Social Work role. • Clearer role for 3rd Sector link workers. • Dual role for CMHT staff. Nurse or Link worker? • Understanding of role is emerging.

  25. Issue: Personal Plan • Example. • Done from ‘scratch’. • Outcomes difficult. • Staff feel there is repetition.

  26. Issue: Personal Plan. • Consider Progress/process to plan and final plan. • What does a plan look like? • Some clients don’t want one. • Pilot version. Biographical. 5 pillars. Risk enablement. Outcomes framework. • 3rd Sector appeared to work. • Nursing feedback. Survey Monkey.

  27. Issue: MacMillan/Alz Scot Long Term Conditions. • Summary of financial gain to November 13 • [Not Specified] £22,965.40 (5 clients) • Attendance allowance £197,571.55 (50 clients) • Blue Badge Application £276.00 (3 clients) • Carer's Allowance £16,220.88 (7 clients) • CHSS Grant £1,350.00 ( 6 clients) • Council Tax Benefit £24,151.70 (44 clients) • DLA - Both £12,617.80 (2 clients) • DLA - Care £34,288.80 (7 clients) • Employment Support Allowance £5,538.00 (1 client) • ESA (Contribution Based) £5,538.00 (1 client) • ESA (Income Based) £14,957.80 (2 clients) • Funeral Payment £1,237.00 (1 client) • H B/Local Housing Allowance £4,115.80 (1 client) • Pension Credit £20,195.73 (4 clients) • Scottish Welfare Fund £670.00 (3 clients) • Vehicle Duty £300.00 ( 2 clients) • Total £371,095.26 (140 clients)

  28. Issue: Outcomes • Back to front approach. • Personal Plan with Outcomes. • But staff not trained in Outcomes. • Training piloted by NES and SSSC. • Can Personal Plan or documentation support/measure outcomes? • Or more about conversations and how it is recorded?

  29. Issue. Role of CPNs. • Dual role. • CPNs shouldn't be doing 2/3 of PDS link working. • Maintain resources for more complex clients and possible 8 pillars. • Allocation on need. • Using band 4 staff in North West. • Integration with SW.

  30. Issue: Role of AHPs • OT staff didn’t linkwork. • Provided aspects of pillars through supported self management. • Two 8 week groups. Practical solutions to managing memory. Peer support. Other agencies. • Need for AHPs re co-morbidity and proposed 8 pillars model. • Best use of AHP resource?

  31. Positives • Vascular dementia • More consistent approach. • Moving to Outcomes. • Greater understanding of roles. • Self management feedback. (Carer/client) • Financial. • Staff have mixed views.

  32. Issue: Could do better • Outcomes. May take years to embed. • Assessing real impact. Qualitative. • PDS service mix. • Clear written protocols on assessment and allocation, roles of link worker. • Allocation by cognitive enhancers. • Learning disability and YOD.

  33. Discussion • Common themes? • Problem solving?

  34. Thank You • Stephen.lithgow@ggc.scot.nhs.uk

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