National Dementia Strategy Objective 8 Improved Care in acute hospitals-how can we achieve this and save money!?

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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

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The Scale of the problem

• In UK gt700,000 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

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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

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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 PCTs

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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

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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

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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

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2009 SHA dementia review

• Peer review
• Baseline assessment
• Good practice highlighted
• Deficits identified
• Advice re implementation of the NDS
• Action plan developed with timeline

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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

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However.

• Many examples of innovative practice
• Liaison nurses in Cornwall inreaching into Care
  Homes to minimise acute transfer
• Life story books
• Rotation of AHPs through MH and acute trusts
• Clothing ID system (BPoole)
• Day ward for wanderers in Dorchester
• GP Academy in Cornwall

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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
  (BPoole)
• Dashboard bed management in Torbay
• Dementia specific intermediate care
• Bristol MH liaison team ?LOS by 3-4 days and
  saved 1million pa

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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

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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

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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

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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

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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

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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

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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

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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-dos
• Clinical dementia lead
• Care pathway in situ and evaluated
• OPMH liaison teams
• Training all staff in dementia

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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

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Summary

• Dont 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