Post Diagnosis Support.Emerging Themes in Glasgow

Stephen Lithgow Dementia Support and Development Lead. GG&C NHS.7th March 2014.

Webex Objectives

Discuss a working model of PDS. Consider a PDS pathway and

delivery mechanisms. Identify strengths and weaknesses

of a PDS model. Explore common issues. Problem solving.

Overview

HEAT Target. Glasgow South PDS. Driver diagram. Key Issues. Discussion (Approx 30 mins).

HEAT Target

The HEAT Target

“ To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a link worker, including the building of a person-centred support plan”.

The HEAT Target

‘Link worker’ - Could be 3rd sector link worker, mental heath staff, Social work or other worker who may deliver support for year.

Use 5 pillars approach. Personal plan. Must be trained to Enhanced Level

of Promoting Excellence.

5 Pillars of Support

The new commitment informed by Alzheimer Scotland “5 pillar” model.

- help to understand the illness and manage symptoms;

- support to stay connected to the community;

- peer support; - help with future decision-making;

- and developing a personalized care plan for their future care.

Glasgow South Sector

Glasgow South Sector.

Population 220,000 (30,00 over 65). Dementia Calculator 2646 prevalence

(Eurocode). 1403 on QoF. 53% of prevalence

diagnosed HEAT target. 327 Incidence. (New clients per year). Require 6-7 W.T.E staff. Based on caseload approx 50.

Delivery Model NHS and 3rd Sector.

NHS/3rd Sector link workers. CMHT (CPN/OT) staff and Alzheimer

Scotland. Based in 2 locations. Elderpark and

Shawmill. One additional Alzheimer Scotland

worker in each team. Change Fund.

What happened.

301 clients in first year. Alzheimer Scotland link worked

approx 100. NHS (CPN) link worked 200. Severity. At least 42% mod to severe.

(20% unknown). Caseloads max around 50.

What happened.

Monthly data returns started. Personal plan developed. Started

using an outcomes approach. Raised £371,000. Piloted supported self management.

Driver Diagram

Pathways to diagnosis and post diagnostic support are clear and understood.

Effective partnership governance of the delivery of the PDS Target.

Data capture and reporting systems in place.

Service Redesign Opportunities have been maximised.

Person centred care approach underpins delivery of all PDS services. (Outcomes).

PDS Pathway. Example.

Data Capture

Monthly returns. Named person in each sector. Shared drive for Health Board. Link workers putting data on

system. Ongoing errors. Co-morbidity. Relative need. PDS Follow up. Longitudinal.

Person Centred Care.

Outcomes and NHS staff. NES and SSSC training. Personal Plan. Using Outcomes. Quantitative and

qualitative recording.

Partnership Governance

Alzheimer Scotland staff co-located in OPCMHT.

Honorary Contracts. Access to Metaframe (NHS e-mail,

PiMS, and shared drive). Patient information. Need to know

basis. Consent. Overarching Health Board

agreement.

Service Redesign

Not like Dem Demonstrators. ‘Minimal disruption’ approach. Adding on resource to existing team

and new skill mix. Use existing health IT, buildings,

resources.

Some Key Issues

Issue: Assessment & Allocation of Link Worker.

Diagnosis- Traditionally cognitive and some functional assessment.

Often more complex needs. Indicator of Relative Need (IoRN). Allocation. Complexity/need but how? Less complex 3rd Sector. More

complex Health. But depends on existing team mix.

Issue: Dementia Severity and Co-morbidity.

35% early. 39% clients moderate. 4% severe. Not known 22%. Physical frailty and co-morbidity across

PDS client group. Light touch theory and often more

complex More than 5 pillars. ‘More 8 pillars....’

Issue: Promoting Excellence

Should be at Enhanced Level. Benchmarking still needs to be

done. Benchmarking tool for link workers? Capture qualifications/training and

work experiences. PDS training. Outcomes training. Sensory impairment.

Issue: Link Worker Case Load.

Ceiling around 50. Needs to consider

complexity/workload with caseload weighting.

3rd Sector clients should be less complex but not always.

Danger of overwhelming staff. Allocation & throughput important.

Issue: Link worker role

Supporting more than 5 Pillars. Complexity. Overlap with proposed 8

pillar/ongoing care. Risk of taking on Social Work role. Clearer role for 3rd Sector link workers. Dual role for CMHT staff. Nurse or Link

worker? Understanding of role is emerging.

Issue: Personal Plan

Example. Done from ‘scratch’. Outcomes difficult. Staff feel there is repetition.

Issue: Personal Plan.

Consider Progress/process to plan and final plan.

What does a plan look like? Some clients don’t want one. Pilot version. Biographical. 5 pillars.

Risk enablement. Outcomes framework.

3rd Sector appeared to work. Nursing feedback. Survey Monkey.

Issue: MacMillan/Alz Scot Long Term Conditions.

Summary of financial gain to November 13 [Not Specified] £22,965.40 (5 clients) Attendance allowance £197,571.55 (50 clients) Blue Badge Application £276.00 (3 clients) Carer's Allowance £16,220.88 (7 clients) CHSS Grant £1,350.00 ( 6 clients) Council Tax Benefit £24,151.70 (44 clients) DLA - Both £12,617.80 (2 clients) DLA - Care £34,288.80 (7 clients) Employment Support Allowance £5,538.00 (1 client) ESA (Contribution Based) £5,538.00 (1 client) ESA (Income Based) £14,957.80 (2 clients) Funeral Payment £1,237.00 (1 client) H B/Local Housing Allowance £4,115.80 (1 client) Pension Credit £20,195.73 (4 clients) Scottish Welfare Fund £670.00 (3 clients) Vehicle Duty £300.00 ( 2 clients) Total £371,095.26 (140 clients)

Issue: Outcomes

Back to front approach. Personal Plan with Outcomes. But staff not trained in Outcomes. Training piloted by NES and SSSC. Can Personal Plan or documentation

support/measure outcomes? Or more about conversations and

how it is recorded?

Issue. Role of CPNs.

Dual role. CPNs shouldn't be doing 2/3 of PDS

link working. Maintain resources for more complex

clients and possible 8 pillars. Allocation on need. Using band 4 staff in North West. Integration with SW.

Issue: Role of AHPs

OT staff didn’t linkwork. Provided aspects of pillars through

supported self management. Two 8 week groups. Practical

solutions to managing memory. Peer support. Other agencies.

Need for AHPs re co-morbidity and proposed 8 pillars model.

Best use of AHP resource?

Positives

Vascular dementia More consistent approach. Moving to Outcomes. Greater understanding of roles. Self management feedback. (Carer/client) Financial. Staff have mixed views.

Issue: Could do better

Outcomes. May take years to embed. Assessing real impact. Qualitative. PDS service mix. Clear written protocols on assessment

and allocation, roles of link worker. Allocation by cognitive enhancers. Learning disability and YOD.

Discussion

Common themes? Problem solving?

Thank You

Stephen.lithgow@ggc.scot.nhs.uk