Integrated Care Pilot: Integrated Care Pilot: An integrated dementia care An integrated dementia care

pathway for Newquaypathway for Newquay

Department of Health Site Assessment18 February 2009

Introductions: Our Partnership Introductions: Our Partnership

Newquay Practice Based Commissioning Locality Group

Commissioning Provision

Service Users and CarersService Users

and Carers

Commissioning ContextCommissioning Context

Dementia is a shared strategic priority

Joint Strategic Needs Analysis

Clinical Dementia Lead appointed

Joint Commissioning Plan

Service Improvement Programme

World Class Commissioning Outcome

07/08

May 08

Jul 08 Newquay PBC Plan

Aug 08

Oct 08

Tim

e

Newquay: Our Accelerator Site

Why Newquay Integrated Why Newquay Integrated Care Pilot?Care Pilot?

We will deliver and add valueWe will deliver and add value• Our commissioning and provider

partnerships brings a– Culture of quality improvement

• Whole System Demonstrator Site• First Wave Improving Access to Psychological

Therapies Site• Exceeded LAA stretch targets for older people

– A history of trust between partner organisations

– Experience and expertise in joint commissioning

• Section 75 Agreement for Adult Mental Health and working towards Learning Disabilities

– Experience and expertise in integrated provision

• Adult Mental Health Services• Integrated Therapies Service• Integrated Rapid Access Teams

We will deliver and add valueWe will deliver and add value– Local leaders, including GPs and clinical

leads who are supportive of integration– Personnel who are open to collaboration and

innovation– A commitment to synergise communications

and IT systems– A strong foundation for success – work

already underway– Excellence in stakeholder engagement –

Older People’s Forums

Newquay Dementia Services Newquay Dementia Services The case for change and The case for change and

integrationintegration

The community systemThe community system

NarrowcliffHealth Centre

Hunter

Dalton HouseHealth Centre

Harper

NQ PBC

Social Care Services

Specialist Older People’sMental Health Services PCT Services

Care Homes

Other Providers

The ideal community systemThe ideal community systemPrevention

Awareness

Recognition

Assessment

Diagnosis

Case Mgmt & Treatments

Unscheduled (and out of hours)

End of Life

Good quality care tailored to dementia

Simple pathways and overlapping services

The community systemThe community system

NarrowcliffHealth Centre

Hunter

Dalton HouseHealth Centre

Harper

NQ PBC

Social Care Services

CPT Services PCT Services

Care Homes

AwarenessRecognitionAssessment

CMHTFunctional /Organic

AssessmentDiagnosis

Case MgmtCrisis Response

Focus on intensive and crisis

AccessCase Mgmt

Crisis ResponseShort TermLong Term

Carer Support

District Nurses

RATS

CommunityHospital

AwarenessRecognition

Rapid ResponsePrimary CareEnd of Life

CommMatrons

Other Providers

Areas for improvementAreas for improvement• Make dementia ‘everybody’s business’ rather than “somebody else’s business”• Focus on prevention – physical health check – vascular checks to prevent

vascular events• Improve awareness and recognition of dementia amongst GPs, health and

social care professionals, including care homes• Increase the number of people receiving an early diagnosis and an annual

health check.

0

50

100

150

200

Anticipated Register Size

August Actual

AnticipatedRegister Size

72 160 70 31

August Actual 31 49 49 7

Hunter Ingle Harper Boulton

Areas for improvementAreas for improvement• Treat dementia as long-term condition and focus on case

management and anticipatory care to – Prevent or defer care home admissions– Prevent of defer hospital admission (especially from care homes)– Reduce length of stay in care homes and community hospitals

• Invest in low-intensity ‘treatment and support options’ and make better use of existing options – e.g. Whole System Demonstrator Dementia Package

• Share specialist expertise with ‘mainstream’ parts of system – – e.g. managing behaviour which challenges – Reduce use of anti-psychotic medication

• Share mainstream expertise with ‘specialist’ parts of system – – e.g. pain management, Liverpool Care Pathway Gold Standard

Framework End of Life care planning

What we did and early learningWhat we did and early learning1) Dementia Liaison Pilot

– QOF Health-checks (Community & Care Homes)– 3 month pilot in 12 care homes – led to commissioning of dementia liaison

service– Partnership with pharmacists – medication reviews

2) GP Led Memory Clinic – Education – anticipation of Dementia Academy 27th March– Opportunistic screening with flu jab– Recognition, assessment, diagnosing and prescribing– Pilot of Locally Enhanced Service

3) GP Based Case Manager– Bring in CPN to work alongside GP practices– CPT Specialist CPN providing post diagnosis care for all patients, including those

with vascular dementias in a primary care setting– Shift from intensive and crisis response to preventative and anticipatory– Simpler systems and paperwork – releasing time to care– Part of virtual team – District Nurses, Community Matrons, Macmillan Nurses,

Social Care (accessing social care budgets)

Early BenefitsEarly Benefits• Increase in numbers on GP registers and

receiving quality annual health checks

0

200

400

Newquay GP Dementia Registers

Actual Nos

Anticipated Nos

Actual Nos 136 192 188

Anticipated Nos 332 332 332

Aug Jan Feb

Early BenefitsEarly Benefits• Assessment & Diagnosis• Early identification of dementia (“memory problems” or cognitive decline)• Normalisation of memory problems

• Care Quality• Increased use of telecare (All GP practices signed up to Whole System Demonstrator

pilot)• Increased expertise in ‘mainstream’ parts of the healthcare system• Easy for the patient, carer and other professionals to understand• Crisis avoidance• End of life care planning

• Benefits to System: Economic• Increased capacity in other parts of the system – reduced referrals to CMHT, freeing

resource for more case management• Reduced hospital admissions

• Case Studies: Assertive Case Finding and the Benefits of early diagnosis

The vision : replicating and The vision : replicating and sustaining success on a larger sustaining success on a larger

scalescale

Social Care

Primary Care

Health Care Secondar

y Care

Because labels create barriers

Integrated Dementia ProvisionIntegrated Dementia Provision• Integrated care – A scaleable model

– Organised around GP practices – Delivering all aspects of care from

diagnosis until end of life for all ages, including people with a learning disability

– A tiered system of case management that supports both the individual and carer access the right treatment and support at the right time

– A flexible, responsive and person-centred care framework which will easily translate into personalised services and individual budgets

– Starting in Newquay before rolling out across Cornwall

Finding people, find them early and giving them the integrated care and support they need.

Tiered Case ManagementTiered Case Management

Consultant

Community matrons

Dementia Case Managers(CPN/District Nurse/Social Worker

Co-ordination and ‘Doing’)

Memory Support Workers

The measurable benefitsThe measurable benefits

• Assessment & Diagnosis

• Quality of Care

• Economic

• Qualitative– Patient– Carer– Staff

Service User & Carer Service User & Carer InvolvementInvolvement

• Older People’s Forums• LINks• Alzheimer Society ‘Discussion Groups’• Established Carer Groups• Visit Memory Cafes• Investment in a Expert Patient and Carer

Reference Group• Use of Advocacy and those with expert

communication skills where necessary• Ongoing communication – e.g. newsletters

Implementation 08 - 09Implementation 08 - 092008 2009 2010

Jan - Mar

Apr –

Jun

Jul –

Sep

Oct - Dec

Jan - Mar

Apr –

Jun

Jul –

Sep

Oct - Dec

Jan - Mar

Apr –

Jun

Jul –

Sep

Oct - Dec

Ongoing Integration of Commissioning & Delivery of Older People’s Mental Health Programme

1

2

3

4a

4b

4c

4d

5

Governance ArrangementsGovernance Arrangements

Provider Steering Committee(To be est)

GPs

CPT

DASC

PCT

New Project Lead

•Roll-out of plan

•Workforce

•IT and information

•Finance

Project SupportData Analyst

•Benefits Tracking

•Programme Management

•Change Management

Operational ProjectGroup (Provision)

PCTCommissioning

DASCCommissioning

PBC

Older People’s Partnership Board

OPMH ProgrammeSteering Group

Operational ProjectGroup (Commissioning)

OPMH ProgMgr

Patient &Carers

ConclusionsConclusions• We offer:

– An outcome-focused pilot with the potential for county and national comparisons– Several unique models of integration– Measurable benefits across a number of domains– Cross-over benefits : Opportunity to show how integration can achieve the

outcomes of the National Dementia Strategy, Carers Strategy and End of Life Strategy

• Integration is the best tool we have to meet our shared economic challenge of rising demand.

– drive a sustainable shift in resources and culture towards early intervention, personalisation and improved outcomes for people with dementia and their carers.

• Integration is the only way to meet the complex and diverse needs of people with dementia

• Integrated services are more satisfying and rewarding places to work• An integrated system frees us to deliver person-centred care