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The Balance of Care Group in association with Lincolnshire Partnership Trust, Lincolnshire PCT, United Lincolnshire Hospitals NHS Trust, Lincolnshire County Council Tackling Dementia Care as a Whole System Tom Bowen, Paul Forte & Dr Chris Foote NAO Conference, London, 12 July 2007. - PowerPoint PPT Presentation
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The Balance of Care Group
in association with Lincolnshire Partnership Trust, Lincolnshire PCT,
United Lincolnshire Hospitals NHS Trust, Lincolnshire County Council
Tackling Dementia Care as a Whole
System
Tom Bowen, Paul Forte & Dr Chris Foote
NAO Conference, London, 12 July 2007
2
Pre admission
Pre admission Admission Diagnosis Treatment Discharge Re-admission
Social details
alone, carers, residence
Risk factors:
age, drugs, co-morbidities,
psychiatric/
dementia, falls
Preventative care
Disease managementManaged populations
Source of referral
Time
Waiting time
Route
Decision maker
Reason for admission
Alternatives to acute admission setting
Admission diagnosis
Inpatient diagnosis
Delays in diagnosis
Chronic disease
Alternative access for diagnosis
Delays in therapy
Alternative settings for therapy (especially rehab)
Discharge planning
Delays in planning
Delays in execution
Alternative sites for discharge
‘Revolving door’
Avoidable e.g. chronic disease management
Alternative sites for readmission
A whole system perspective
3
The Lincolnshire bed usage survey
• To identify the number and types of inpatients
currently receiving hospital care (acute and non-
acute) who might potentially have:
– been treated elsewhere and avoided admission
– required admission, but could now be treated elsewhere
– particular emphasis on people with dementia
4
The Lincolnshire bed usage survey
• To identify the number and types of inpatients
currently receiving hospital care (acute and non-
acute) who might potentially have:
– been treated elsewhere and avoided admission
– required admission, but could now be treated elsewhere
– particular emphasis on people with dementia
• Point prevalence survey on 29 November 2006
– All medical and orthopaedic inpatients (667)
– All intermediate care inpatients (121)
– All OPMH inpatients (75)
5
Age Distribution of Patients by Type of Bed (N=860)
0
50
100
150
200
250
Under 65 65 to 74 75 to 84 85 & over
No
of
pa
tien
ts
A -acute
B intermediate care
C - OPMH
6
Proportion of Patients with Mental Health or Cognitive Issues (N=863)
Dementia13%
Confusion14%
Anxiety/depression8%
Psychosis2%
Substance Misuse2%
Other1%
No mental health issue60%
7
Location of Patients by Mental/Cognitive Issue (N=344)
0
20
40
60
80
100
120
140
Demen
tia
Confus
ion
Anxiet
y/dep
ress
ion
Psych
osis
Substa
nce
Misu
se
Other
No
of p
atie
nts
OPMH
Intermediate care
Acute
8
Occurrences of comorbidities in dementia patients
0
5
10
15
20
25
30
Heart
failu
reIH
D
COPD
Diabet
es
Parkin
sons
Hyper
tensio
n
Arthrit
is
Cance
r
Cereb
rova
scul
ar
No
of o
ccur
renc
es
OPMH
IC
acute
9
Comorbidities for Patients with Dementia (N=111)
0
5
10
15
20
25
30
35
0 1 2 3 4 5
Number of comorbidities
No
of
pa
tien
ts
OPMH
IC
acute
10
Assessed risk of 'confusion' patients having dementia (N=119)
0
10
20
30
40
50
60
High Medium Low
Assessed risk of dementia
No
of
pa
tien
ts
OPMH
IC
acute
11
Appropriateness Evaluation Protocol
On admission
• Severity of illness eg unconscious, unable to move (fall), acute bleeding
• Intensity of service eg surgery + general anaesthesia, regular monitoring, IV
therapy
On day of care• Medical services
• Nursing services
• Patient conditioneg acute confusion, other acute states, coma, fever
12
Percentage of Acute Inpatients within AEP Criteria(Dementia = 65, all other = 602)
83%
32%
85%
53%
0%
20%
40%
60%
80%
100%
on admission on day of care
% o
f pat
ient
s w
ithin
AE
P c
riter
ia with dementia
all other
13
Alternatives to Continued Stay for Acute Hospital Patients with Dementia (N=43)
0
2
4
6
8
10
12
Own
Home
Home
& Socia
l Car
e
Home
& Gen
eral
Hea
lth C
are
Home
& Reh
ab S
uppor
t
Home
& Spec
ialis
t Nurs
e
Acces
s to
Out
patie
nts
Non A
cute
Bed
& T
herap
y
Non A
cute
Bed
Home
& Spec
ialis
t Hom
e Car
e
Home
& MH S
uppor
t
Home
& MH R
ehab
Suppo
rt
Non A
cute
Bed
& M
H The
rapy
Acute
MH B
ed
EMI C
ont C
are
Bed
Oth
er
No
of p
atie
nts
Quick discharge
Remaining
14
Alternatives to Continued Stay for OPMH Patients with Dementia (N=34)
0
2
4
6
8
10
12
14
16
Own
Home
Home
& Socia
l Car
e
Home
& Gen
eral
Hea
lth C
are
Home
& Reh
ab S
uppor
t
Home
& Spec
ialis
t Nurs
e
Acces
s to
Out
patie
nts
Non A
cute
Bed
& T
herap
y
Non A
cute
Bed
Home
& Spec
ialis
t Hom
e Car
e
Home
& MH S
uppor
t
Home
& MH R
ehab
Suppo
rt
Non A
cute
Bed
& M
H The
rapy
Acute
MH B
ed
EMI C
ont C
are
Bed
Oth
er
No
of p
atie
nts
Quick discharge
Remaining
15
Some Key Points
• 111 out of 863 patients surveyed (13%) had a recorded dementia diagnosis
• 65 were in acute hospital• There may be substantial under-diagnosis or
under-recording of dementia• Majority of acute hospital patients with dementia
were outside AEP criteria on the day of the survey• Potential alternative care settings cover a wide
range of services, specialist coordination may be needed
• Demand for rehab support for people with dementia
16
17
Source of Referral for Patients with Dementia - Acute (N=65)
Referral by GP18%
Seen by GP17%
99943%
Self2%
Other Hospital
2%
Other/nk18%
Source of Referral for Patients with Dementia - OPMH (N=40)
Referral by GP32%
Seen by GP5%
Other Hospital
15%
CMHT18%
Crisis Team8%
Other/nk22%
18
Comorbidities for Patients at High Risk of Dementia (N=30)
0
2
4
6
8
10
12
14
16
18
0 1 2 3 4 5
Number of comorbidities
No
of p
atie
nts
OPMH
IC
acute
19
Preferred Alternatives to Admission for Dementia Patients (N=36)
0
1
2
3
4
5
6
7
8
Home
& Soc
ial C
are
Home
& Gen
eral
Health
Car
e
Home
& Spe
cialis
t Hom
e Car
e
Non A
cute
Bed
Non A
cute
Bed
& T
hera
py
Carer
Res
pite
Home
& MH S
uppo
rt
Psych
OP
Non A
cute
Bed
& M
H The
rapy
EMI C
ont C
are
Bed
No
of p
atie
nts
OPMH
IC
acute
20
Admission criteria of ULH patients with dementia (N=65)
0
5
10
15
20
25
0 1 2 3 4 5
Number of comorbidities
No
of
pa
tien
ts
other
A1
outside AEP
