The Eastern Region Darzi Review on dementia - the proposed ...

1. Darzi Review Eastern Region Dementia Care Pathway Louise Molina, CSIP

2. Key Principles Person, family, carers and social networks are at the centre of the pathway People with dementia (PWD) are assisted to make decisions about their own health and care Emphasis on promoting independence and preventing crisis Carers role must be acknowledged and supported An integrated �one team approach� to providing care Integrated approach to commissioning and providing services

3. The Care Pathway1. Information In order to raise public awareness and understanding of dementia, reduce stigma and therapeutic nihilism, and encourage early presentation, detection and diagnosis there needs to be widely available, reliable information as a public health objective. Commission �Information Prescription� services Promoting a healthy lifestyle needs to be encouraged to help delay the onset of dementia by reducing the risk of vascular disease (Kokmen et al 1996, Stewart 2002).

4. 2. Primary Care Screening Primary care services to screen patients form known at risk groups � patients with CHD GPs to undertake routine medical check and bloods on referred patients

5. 3. Single Point of Access to OPMH Services New referrals will be forwarded to the relevant consultant team Secretary will call patient so that patient can choose a time to see the consultant and book that appointment SPOA number will be available for PWD and carers to call for advice

6. 4. Diagnosis The majority of people will be diagnosed by an Old Age Psychiatrist, preferably in their home environment Follow up visit within 2 weeks by the CMHT New lasting �Powers of Attorney� to be encouraged for early planning of later stages of dementia Trial of Cholinesterase Inhibitor to be considered for all relevant patients All patients diagnosed via a Neurologist or Learning Disabilities Psychiatrist to be referred on the OPMH CMHT for further diagnostic counselling and support

7. 5.Integrated OPMH CMHT Each team to co-ordinate care of all PWD in a locality, reviews being managed by a database with an alert system Team members to include: Old Age Psychiatrists, Psychologists, Specialists Nurses, CPNs, Support Workers, Specialist AHPs, Social Workers and the Voluntary Sector The team will provide in reach to the Acute Trust The team will liaise with the CRHT during day office hours

8. 6. Care at home (1) A variety of services can be commissioned to provide care at home, to include: i) Specialist home carers ii) Extra care housing iii) Assistive Technology Support Workers iv) Voluntary sector services

9. Care at home (2) vi) Access to short break (respite) care, night sitting services, and specialist out of hours care All of the above can be supported by widespread use of direct payments and individual budgets. PWD may also be eligible for NHS Continuing Care (Continuing Care Framework DH 2007)

10. 7. Short Break (Respite) Care Needs to be flexibly and locally available No financial barriers to accessing short breaks Aimed at promoting the well being of the PWD as well as carers It should be noted that care provided at home by a carer (not including workers for statutory, voluntary and independent sector organisations) is an essential part of keeping PWD independent within their own home. The value of this care, as a means of reducing premature admission to care homes or avoidable admission to hospital, should not be underestimated. Respite care should be considered as a preventative measure for both of the above and this report recommends that commissioners value this care when commissioning services.

11. 8.Crisis and OOH services Emphasis should be on crisis prevention Services provided by health, social care and voluntary sector should be co-ordinated In addition to primary care OOH services and local authority OOH services, the following should be available: An OPMH CRHT to provide planned and unplanned telephone advice, domiciliary assessment and treatment Flexible use of intermediate care services

12. 9.OPMH Liaison Service Nurse led service, supported by Psychiatrists Assist in early identification, assessment, management and onward referral of older people with mental health problems in Acute Trusts Liaise with Discharge Co-ordinators and CMHT to plan discharge and prevent delayed discharges

13. 10.Residential Care Promote well being through person centred care People should not be moved between residential care homes as a result of dementia diagnosis Sustainable training programmes to be provided for third sector staff to ensure high quality care

14. 11.Inpatient and intensive care Specialist staff should be available who have received training in dementia care The specialist staff may also deliver the CRHT service and will work closely with the CMHTs. Early discharge planning in partnership with carers should begin as soon as possible after admission.

15. 12. Younger People and People with Learning Disabilities Due to the very individual needs of both YPWD and people with learning disability who develop dementia, and their carers, the OPMHT CMHT will include expert leads for these two groups of people. The LD dementia lead will liaise with local LD services.

16. 13.Advocacy Services An Independent Mental Capacity Advocate (IMCA) should be available to assist in the care of all PWD, when required

17. 14.End of life care In partnership with carers, the CMHT will be best placed to decide when a PWD is reaching the end of their life. The CMHT will liaise with Palliative care colleagues to ensure a PWD palliative care needs are met. The quality of care should be to �Gold Standards Framework� standards

18. 15. Alcohol related dementia Further work is needed to improve liaison between dementia services (CMHTs) and drug and alcohol services to ensure timely diagnosis, treatment and support for PWD and alcohol related problems.

19. Deficiencies in Eastern Region (1) Almost complete absence of routine screening for dementia in primary care and appropriate signposting from the Acute Trust for follow up. Lack of sustained training and support programmes for health and social care professionals and other people caring for people with dementia. This has led to a lack of specialist knowledge amongst professionals who work with PWD. Severely under-resourced or absent OPMH liaison services in many Acute Trusts

20. Deficiencies in Eastern Region(2) Integration of OPMH teams with generic health and social care services is patchy across the region, leading to fragmentation of services. Lack of residential care beds in some areas. Limited post diagnostic psychotherapeutic counselling and support for service users or carers for PWD. Lack of integrated commissioning arrangements between health and social care

21. Recommendations (1) Improve joint commissioning and providing of services between health and social care, including action plans on how to integrate health and social care within OPMH teams. Make the development of early detection programmes in primary care a QOF target. Dementia should be a mandatory indicator in the World Class Commissioning Framework for Primary Care Trusts.

22. Recommendations (2) The Darzi Staying Healthy Group recommendations must be supported, because of their potential to prevent or delay the onset of dementia. Targets to promote high quality cardiovascular care, as set out in the NSF for Coronary Heart Disease (DH 2000) and the Quality and Outcomes Framework (DH 2003), should continue because of their potential to prevent or delay the onset of dementia. The current expert patient programs should be further supported and expanded to enable PWD, and carers, to become key decision makers in their treatment (DH 2001)

23. Recommendations (3) Training around dementia, skills, attitudes and dignity should be an integral part of foundation training of health, social care and third sector staff. Training should include the differential diagnosis between delirium and dementia to all health care staff, including OOH staff, to prevent avoidable admission. Sustained, specialist vocational courses on dementia should be commissioned for staff who work directly with people with dementia. Links to university colleagues should be encouraged. Regulator Standards for dementia care settings should include Workforce Training in Dementia Care

24. Quality Indicators (1) Joint commissioning, led by the SHA, to be implemented across the region by April 2009 Using existing CHD disease registers instigate the development of early detection programmes in primary care as a National QOF target by April 09. Rates of detection in primary care (targets for %age of expected cases identified) monitored from April 09. Minimum core standards for training programmes on dementia should be detailed in commissioning plans by December 08.

25. Quality Indicators (2) Levels of prescribing of cholinesterase inhibitors (target to be top third in Europe by December 2008; currently in bottom third of Europe (Mental Health- Supporting Information, Data and Evidence, NHS Next Stage Review Sept 07) Time of referral to specialist treatment by the OPMH CMHT should not be longer than 18 weeks, which includes time to assess and confirm diagnosis. This is in accordance with the National Standards on access. CRHT: 24/7 telephone advice and support, and specialist OPMH CRHT available between 7am and 9pm every day of the year by April 09

26. Priorities for Action Screening of at risk groups in Primary Care Joint commissioning and providing of services between health and social care Improved training around dementia for all people involved in the care of PWD Widespread development of older people�s liaison services