City & Hackney Integrated Dementia Care Pathway Overview

Transcription

1 Primary Care: Maintenance of primary care Dementia Register, 15 month Primary care physical and mental health review of people on the register Dementia Advisers providing advice, information and support to people with a diagnosis of dementia with low to medium intensity needs via support plan Memory Service providing assessment; 12 week post diagnostic care plan; periodic support for people with medium intensity needs; Awareness raising and skills development City & Hackney Integrated Dementia Care Pathway Overview Awareness Raising Promotion and Skills Development Pre-Diagnosis Support Identification When memory problems has prompted an approach to GP Assessment and Diagnosis Learning that the condition is dementia Living well with Dementia Learning more about the disease, options for treatment and support Getting the Right Help at the Right Time Living well with Dementia (Personalised health and social care in the community) Preventing Crisis; Managing Together Living well with Dementia (Carers) Getting help if it is not possible to Stay at Home Living well with Dementia (Hospital care) End of Life Care Receiving compassion and support at end of life Dementia Alliance 11 th May 2016 Page 1 of 7 Version 1

2 Integrated Dementia Care Pathway-Individual Pathways Awareness Raising, City & Hackney Awareness raising, advice, information, support and promotional events E: T: Mon-Fri: 9-5pm Promotion initiatives aimed at general population Promotion initiatives aimed at target communities including BME communities and hard to reach groups Training for front line staff (including voluntary sector, care homes, housing with care schemes) Development sessions for primary care Dementia Champions GP Lead Hackney Caribbean Elderly Association Memory group, information and support 39 Leswin Road London N16 7NX E: T: Mon-Fri: 10-5:30pm Dementia Alliance MCI group, CST group Training and support to frontline staff at Housing with Care Schemes Homerton University Hospital (HUH) Training to frontline staff at HUH Mandatory Dementia Awareness training to all new staff at HUH John s Campaign (Carers Passports)- The right to stay with people with dementia in hospital Bikur Cholim Ltd Services for people living with dementia including carers assessment Ground Floor, 2a Northfield Road London N16 5RN E: Reception@bikurcholim.co.uk T: AgeUK, East London T: Jewish Care -Brenner Centre Raine House, Stamford Hill, London, N16 5TP E: helpline@jcare.org T: Mon - Thurs 9am pm, Fri - 9am - 1pm Alevi Cultural Centre and Cem-evi (Turkish) Drop in advice and information 89 Ridley Road, E8 2NH; E: cemevi@live.co.uk T: /6285 Mon-Sun: 9-5pm 22 Dalston Lane, Hackney, E8 3AZ Info & Advice: Mon-Fri 9.30am-1pm Drop-in: Mon 2-4pm, Wed 9:30-1pm Pre-Diagnosis Support Triage Support to concerned person/family who needs help to articulate what to say to the GP City of London Memory Group for adults without formal diagnosis but also open to those living with dementia Prevention & Early Intervention Dementia Alliance 11 th May 2016 Page 2 of 7 Version 1

3 Primary Care: Maintenance of primary care Dementia Register, 15 month Primary care physical and mental health review of people on the register Awareness raising and skills development Phase1: Identification-Screening Pathway When memory problems has prompted an approach to GP - Dementia Advisors linked to Memory clinics and CCG quadrants - Directory of services on website - ICARE Screening for people at risk Use of standardised screening tool and referral protocol GP Lead Acute Hospital/A&E (HUH) Patient with new diagnosis of suspected dementia Check FBC, U+E, TFT, AST, HbA1c Haematinics Do GPCOG test Rule out other causes/delirium Suspected new diagnosis of dementia Refer to Memory clinic, Felstead Street. Please include contact number for a carer/the patient and the Hackney Care Plan if patient has consented to sharing with healthcare professionals Alcohol related memory problems/unsure of diagnosis Contact memory clinic for advice in writing or by before referral E: Sandra.evans@eastlondon.nhs.uk or cianan.osullivan@nhs.net Patients will be discussed at Memory MDT and sent appointment within 4 weeks of referral Initial appointment: Patient offered MRI /CT scan, and cognitive assessment. Follow up appointments: Patients will be given a diagnosis within 12 weeks of first assessment in most cases Dementia Alliance 11 th May 2016 Page 3 of 7 Version 1

4 Primary Care: Maintenance of primary care Dementia Register, 15 month Primary care physical and mental health review of people on the register Awareness raising and skills development Phase2: Assessment & Diagnosis Pathway Learning that the condition is Dementia Carers Assessment Information, advice, signposting and support Needs assessment Mild Cognitive Impairment (MCI) NOT dementia Referral to Memory Service for full multidisciplinary assessment including investigation and diagnosis 12 week post diagnosis care plan including treatment with antidementia drugs, diagnostic counselling, psychological therapies, compensatory strategy work including skills and ADL maintenance Carers assessments Home Visits undertaken if indicated nearly always for DCT Mild to moderate dementia DCT Support to Care Homes & Supported Living Scheme High risk/severe dementia/behavioural and psychological symptoms of dementia Memory Service Full multidisciplinary assessment Investigation and diagnosis Carers assessment At ANY point throughout pathway, Patients can be referred to dementia advisers (The Alzheimer s Society) Patients will be offered cognitive stimulation therapy Patient will be discharged with advice about MCI; refer to MCI/CST group If memory concerns worsen, GP to re-refer to memory service. Suggest annual review of memory Patient offered cognitive stimulation therapy, support groups Patient may be initiated on dementia medications Referred to the Dementia Care Team for risk assessment, mental healthcare, care package assessment May be referred to supported living schemes, sheltered housing, or residential home if unable to live Once patient is stable, and no longer high risk, may be discharged from dementia care team to Carers will be offered carers support groups (Alzheimer s Society; Carer Centre, St Joseph Hospice; Bikur Cholim-Jewish org) Patients/Carers will with GPCOG Once patient is stable can be discharged to primary care for ongoing prescription of dementia medications and annual review at home due to risk social services for ongoing social care be offered programmes such as Singing for the Brain, and Living well with dementia If patient becomes high risk/worsening symptoms, they should be referred back to the dementia care team Memory Service providing assessment; 12 week post diagnostic care plan; periodic support for people with medium intensity needs; Care Coordination under CPA for service users with high intensity needs Dementia Alliance 11 th May 2016 Page 4 of 7 Version 1

5 Primary Care: Maintenance of primary care Dementia Register, 15 month Primary care physical and mental health review of people on the register Awareness raising and skills development Phase3: Living well with Dementia Learning more about the disease, options for treatment and support Memory Service providing: Assessment 12 week post diagnostic care plan Out patients for people with medium intensity needs DCT-Care Coordination Under CPA for service users with high intensity needs Regular review in line with service user and carer needs Support plan for all service users with a diagnosis including names specialist follow up depending on need Carers assessments conducted routinely by dementia Assessment Worker Dementia Advisers providing advice, information and support and signposting for people with a diagnosis of dementia with low to medium intensity needs via support plan Carers Assessment Phase4 (a): Getting the right Help at the Right Time Living well with Dementia (Personalised Health and Social Care in the Community) LB of Hackney & City of London Quality assured care homes Training in person centred care for staff in care homes Personal budgets & Telecare Befriending and Shopping Service Dementia Alliance: MCI group, CST group Dementia Care Training Peer support groups Specialist home carers skilled in supporting people with dementia Specialist respite care Specialist extra care sheltered housing Specialist day care Quality Assured care homes with staff trained in person centred dementia care Access to ICARE One Hackney and City of London Better co-ordinated and continuous care Trowbridge specialist centre: Activities for adults with learning disabilities and dementia Referrals via Information and Assessment Team 1 Trowbridge Road, E9 5LD E: info@hackney.gov.uk; T: Marie Lloyd Day Care Centre: Activities/lunch for service users 65+: referrals via ACMT 329 Queensbridge Rd, E8 3LA E: access@hackney.gov.uk; Dementia Advisers providing advice, information, support and signposting for people with a diagnosis of dementia with low to medium intensity needs via support plan Dementia café The Hackney Coffee Club Singing for the Brain TCCR-Tavi Group (Pilot project-ends Sept 2016) Couples Therapy & Staff Training T: E: ltwd@tccr.ac.uk Mon-Thurs: 8-10pm; Fri: 8-9:30pm/Sat 8-1pm Dementia Alliance 11 th May 2016 Page 5 of 7 Version 1

6 Memory Service providing assessment; 12 week post diagnostic care plan; periodic support for people with medium intensity needs; Care Coordination under CPA for service users with high intensity needs Dementia Alliance 11 th May 2016 Page 6 of 7 Version 1

7 Awareness raising and skills development Primary Care: Maintenance of primary care Dementia Register, 15 month Primary care physical and mental health review of people on the register Dementia Advisers providing advice, information, support and sign posting for people with a diagnosis of dementia with low to medium intensity needs via outcome plan Memory Service providing assessment; 12 week post diagnostic care plan; periodic support for people with medium intensity needs; Care Coordination under CPA for service users with high intensity needs Phase4 (b): Preventing Crisis, Managing Together Living well with Dementia (Carers) Marie Lloyd Day Care Centre: Support for carers to enable service users to remain at home and avoid residential care Dementia Alliance: Dementia Care training Namaste Volunteers (St Joseph Hospice) Home visit for those with advanced dementia Carers support groups Memory Service Carer assessment and support planning including psychological therapies Training programmes for all Health Care Providers City of London Carers Group & Wellbeing Support Group for adults with additional needs : Carers Information and Support programme Self-facilitated Carers Support Groups Carers Assessment Review and Support service TCCR-Tavi Group (Pilot project-ends Sept 2016) Couples Therapy & Staff Training T: E: ltwd@tccr.ac.uk Mon-Thurs: 8-10pm Fri: 8-9:30pm/Sat 8-1pm Memory Service Carer Assessment and support planning Psychological Therapies Phase5: Getting Help if it is not possible to Stay at Home Living well with Dementia (Hospital Care) LB of Hackney & City of London Residential Care Nursing Home provision Access to support in crisis including inpatient care Rapid assessment for patients suitable for discharge with appropriate support and planning Psychiatry Liaison service: Provides assessment, care and discharge planning, advice, consultation and liaison to service users and teams at HUH GP Phase6: End of Life Care Receiving Care, Compassion and Support at the End of Life End of life care pathway for people with dementia Bereavement support for carers across all settings including home, care homes Care coordination and hospital Community and care home End of Life Facilitators with skills in and responsibility to support people with dementia who are dying and professionals involved in their care Dementia Alliance 11 th May 2016 Page 7 of 7 Version 1

8 Marie Curie & St Joseph Hospice: Provides end of life care and support to people with dementia their carers and professionals involved in their care Dementia Alliance 11 th May 2016 Page 8 of 7 Version 1

9 Glossary Terms ACMT AST Test CCG CPA CST CT DCT FBC GP GPCOG HbA1c HUH LB MCI MDT MRI TCCR TFT U+E Assessment and Care Management team Aspartate Aminotransferase Test Clinical Commissioning Group Care Programme Approach Cognitive Stimulation Therapy Computed Tomography Dementia Care team Full Blood Count General Practitioner General Practitioner Assessment of Cognition The Haemoglobin A1c Homerton University Hospital London Borough Mild Cognitive Impairment Multi Disciplinary Team Magnetic Resonance Imaging Tavistock Centre for Couple Relationships, Counselling and Psychotherapy Services Thyroid Function Tests Urea, Electrolytes & Creatinine. Dementia Alliance 11 th May 2016 Page 7 of 7 Version 1