Changing practice to reduce admissions for people with dementia

1. Changing practice to reduce admissions for people with dementia Dr Afifa QaziConsultant Old Age Psychiatrist Havering older people’s services afifa.qazi@nelft.nhs.uk

2. Evolution of older people’s services • Institution to Care in the community • Geriatric services 1940s • Psycho-geriatric services 1960s • Day hospitals • Community mental health teams • Changing role of the consultant

3. National Dementia Strategy Improved community support services Living well with dementia in care homes • New Ways of Working DOH 2005 improving relations with primary care and community • NICE Guidance for Dementia - support people with dementia in the community as far as possible

4. Components of the service • Community Mental Health Team • Memory clinic / out-patient clinic • Home Treatment Team • Liaison service • Day hospital • In-patient ward

5. Diagnosis Follow-up Crisis management Acute Chronic Preventative Dementia care

6. Population • Havering , borough with most older people Office of National Statistics 2008 • 40,700 over 65yrs • 3400 with dementia • 30% (1100) of those in care homes • Three psychiatric teams covering roughly the same catchment-areas • Very low admission rates

7. Inpatient admissions Havering(04/09 to 03/10)

8. Admissions for Team A(04/09 to 03/10)

9. Average length of stay

10. Bed usageApril 09 – March 10

11. Inpatient Admissions NELFTper 10,000 population

12. Average length of stay - NELFT

13. Bed Daysper 10,000 population

14. Bed Occupancyper 10,000 population

15. Source of referrals • G.P s • Elderly medicine and neurology • District nurses • Care homes

16. General practice • Close working links with GPs/practice nurses, consultant mobile number • Excellent secretarial support • Quick response (same day) • Talks at surgeries leading to improved quality of referrals, improving GP confidence in managing psychiatric disorders • GPs not good at detecting and managing dementia ( “Forget me not” 2002 audit commission) • Face to face discussions (eg referral for acute confusion)

17. Care homes (1/3rd of people with dementia) • Close working links with homes & consultant mobile number • Prompt response • Training sessions, talks • Regular “surgeries” at homes with “problems” • Able to identify difficulties before reaching crisis point • No admissions from care homes over last 2 yrs

18. CMHTsingle point of access • Weekly meetings, discussions • Joint visits • Close links • Home visits 5 days a week • Prompt response and consultant mobile number encouraged to call

19. Out patient clinics • Emergency slots for patients in a crisis situation • Frequent follow ups for acutely unwell patients (2-4 weekly) • Encourage patients to ring in case of problems (provide contact sheet to all ops with secretaries number)

20. Patients not falling within day hospital or HTT • Case 1 Mrs EE • Case 2 Mrs ES

21. Key elements • Access - support • Training – development • Liaising- providing the missing link TEAM EFFORT

22. Conclusion • Bed occupancy - <10% of RCPsych recommended bed numbers • 1/4 of beds of average NELFT consultants per 10,000 population • 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