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,
it has given us a lot of
help
The programme has
given me ideas I
never would have
thought of
It has taught us how to
work on the things
that matter, and ignore
the things that don’t
I feel like I have a
purpose when
spending time with
dad
The programme has
given me more
tolerance
It made us realise that
parts of mum’s
memory work, and
others don’t
I cannot say how much
of a difference this has
made to my relationship
with my mother
We’ve had some nice
enjoyable times doing
the activities together
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 [email protected]
UCLPartners - dementia stream
Improving care in general hospitals
Involving
families/carers
Managing
delirium
Education &
training
BEH + NMUT
CIFT + UCLH + RFH
ELFT + BLT
NELFT + BHR
Joined-up
working
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
1600
1400
1200
1000
800
600
400
200
0
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team I
Low bed base
Bed Occupancy
per 10,000 population
16
14
12
10
8
6
4
2
0
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team I
RCPsych
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’
Committee (ETSC)
Education, Training and Standards
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
[email protected]
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
population of people >65yrs is approx
63,544 of whom 4,458 (14%) have
dementia***.
 Locally (Outer North East London
boroughs) prevalence data for adults
>65yrs reported for 2009,** shows:
Borough
Population
65+
Dementia
%
Barking & Dagenham
21 227
1732
8
Havering
37 246
2807
8
Redbridge
31 483
2428
8
Waltham Forest
25 397
1895
7
ONEL total
115 353
8862
8
 Currently across NELFT there are
varying levels of work/engagement,
this varies by business unit and also by
borough, much of this relates to the
historic levels of investment in
dementia services
*Source: DoH 2009
**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
Band 7
ADMIN
RMN
Band 7
RGN
Band 6
RMN
Band 6
Support
Worker
Band 3
Support
worker
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;
•Identify
and review PWD or those experiencing memory problems and
support in the community.
DIST Pathway
Referral to DIST via
•Community Services
•GP’s
•Ambulance Referral
•AAT
•Wards
•3rd Sector
•Individuals
Referred to/
Follow-up by DIST
up to 6 weeks
•
•
•
•
•
•
•
•
•
•
Memory Service
CMHT
Inpatient Services
MH & Community Hospital
Reablement
Social Services
Care Home
Liaison Team
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
referrals
402

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:
[email protected] (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
 Building
on 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
[email protected]
[email protected]
[email protected]
Background slides
Another slide for CQUIN
Dementia and Mental Illness
in our 4 boroughs
From 2009
Population
65+
Barking and
Dagenham
21,227
Havering
Depression
Schizophrenia
36 1,732
3,184
212
37,246
57 2,807
5,587
372
Redbridge
31,483
57 2,428
4,722
315
Waltham
Forest
25,397
48 1,895
3,809
254
ONEL Total
115,353
8,862
17,302
1,153
7.7% (0.2%)
15%
1%
Percentage
Dementia
What we offer from NELFT
Mental Health Services
Older
Adult
Memory
Services
Admiral
Day
Services
Liaison
Home
Treatment
Team
Nurses
Mental
Including
YPD
Team
B&D
Yes
Yes
Two
Yes
Queens
Collaborative
Care Team (CCT)
Yes
Redbridge
Yes
Yes
Two
Groups
King Georges /
WXH 2 nurses
Yes
Havering
Yes
Yes
Two
No
Queens CCT
Yes
Waltham
Forest
Yes
Yes
One
Yes
Whipps Cross 1
nurse
No
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.
 Depression: associated with increased
LOS, mortality rates, health
care costs and dependency. Low detection rates
 Solutions…. Liaison can
improve outcomes (clinical, LOS, readmission 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

Signposting

Mindfulness-based Cognitive Therapy

Anxiety Management

Mental Health Promotion

Admiral Nurses engagement with carers

Support
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
 Acceptance of
patient stable and carer agreeable
future 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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Dementia presentations - North East London NHS Foundation Trust