Sandra Gracie Strategy Development Officer Project Lead Test Site Work. Moray Community Health and Social Care Partnership

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1 Sandra Gracie Strategy Development Officer Project Lead Test Site Work Moray Community Health and Social Care Partnership

2 Moray Background Dementia one of seven key priorities identified in Moray JCS for Older people Dementia work stream established to consider the options and develop a delivery plan Moray Joint Dementia Strategy developed Secondary care work through OPAC Explore an integrated community model of care which considers the range of care and support required throughout the progression of the symptoms of dementia

3 Dementia specific Change fund investment Digital Reminiscence therapy units Reminiscence boxes in Libraries Alzheimer Scotland community activities organiser post Post Diagnostic Support Dementia development Nurse in Acute Further development of dementia cafes 20% carers support - dementia training for carers, dementia specific peer support, Carers short break bureau

4 Expression of Interest EoI submitted to national team 8PM Background information requested Invitation for interview Successful in becoming a test site

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7 Target to increase number of people with a diagnosis of dementia delivered nationally across Scotland. Embedded within HEAT Target on Post Diagnostic Support. working with partnerships to improve diagnosis rates and the quality of post diagnostic support 10 care actions identified Supporting the Alzheimer Scotland Dementia Nurse/Allied Health Professional Consultants in each Board to test and evaluate change ideas to deliver improvements in care for people with dementia in acute hospitals Supporting 5 partnerships in Scotland to test an integrated and comprehensive, evidencebased approach to supporting people with dementia and their carers in the community. Aim: to improve experience, safety and coordination of care for people with dementia, their carers and staff by January 2016.

8 Key Contacts Post Diagnostic Support Michelle Miller, National Improvement Advisor k Douglas Philips, JIT Dementia Lead 8 Pillars Amanda Johnson Dementia in Acute Improvement Lead uk Policy Lead Dementia: David Berry Administrative Support: Mel Young Michelle Miller, National Improvement Advisor Douglas Philips, JIT Dementia Lead Eileen Moir (JIT Associate) David Piggot (JIT Associate) Kiran Haskar (Policy Support) Senior Information Analyst: Dionysis Vragkos dionysis.vragkos@scotland.gsi.gov.uk

9 The 8 Pillars Model provides a comprehensive integrated and coordinated approach to supporting people with dementia and their families and carers. Enhancing resilience of people with dementia and their families and carers: equipping and supporting them to cope with symptoms of moderate to severe stage of the illness.

10 Highland Moray Testing across a range of settings Rural and Urban Health, Local Government, Integrated Services Multidisciplinary Teams Glasgow City North Lanarkshire Midlothian Glasgow (city) Highland Midlothian Moray North Lanarkshire

11 Aim To improve the experience, safety and co-ordination for people with dementia, their carers and staff in identified test sites by January 2016, through testing and evaluating a range of approaches to providing better integrated care and support using 8 pillars Primary Drivers Dementia Practice Coordinator Therapeutic Interventions to tackle symptoms of the illness General health care and treatment Mental health care and treatment Personalised support Support for carers Environment DRIVER DIAGRAM Secondary Drivers Identify and appoint Dementia Practice Co-ordinator (DPC) DPC will ensure co-ordinated approach to providing support Ensure appropriate therapeutic interventions are available, determined by individual circumstances, as assessed by DPC & specialist colleagues. Ensure a mandatory 15 month GP check-up Co-ordinated by the DPC, a multidisciplinary approach will be adopted. The DPC will liaise with psychiatrists and community mental health team, to facilitate transfer of knowledge and social care and health working together The DPC will assess the person s requirements and ensure support delivers their key outcomes. Evolution towards self-directed support will assist people to make best use of resources. Interventions for carers will be delivered across health and social care disciplines. The DPC will identify the individual needs of the carer and link with the appropriate practitioner or service. Individual assessment carried out to determine requirements DPC responsible for linking with appropriate practitioner or service Community Connections The DPC will work with the person and their carer to enable risk, plan purposeful community activity, maintain or regain connections and access peer support. The DPC will engage with community development to use and be fully included in mainstream community activity.

12 Improvement Collaborative Approach Total: 8 learning sessions with action review periods Action Review Period Action Review Period Change package development Measurement Framework development Data collection

13 How will we know we are making a difference? PDS Status Report Essential Quality Criteria Improvement data and case studies National Benchmarking data Qualitative + Quantitative Data Collection and analysis Improvement data Flash reports, case studies Improved Safety Improved Experience Improvement data Flash reports, case studies Measurement Framework Feeling supported Feeling safe Improved Co-ordination Feeling responded to

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15 What support have we received What support have we given. Support improved knowledge and understanding of improvement Share learning and examples of good practice Signpost to new and existing resources Support with evaluation and outcomes Attend and contribute to webex sessions (x4) and learning sessions (x5) Provide Flash Reports to share progress and learning (x6) Shared our practice Produce a case study to share results and to publish findings

16 Getting started Steering Group established A successful launch event Initial Mapping Exercise DPC s identified sub group Benchmarking Change package and measurement plan

17 Benchmarking Retrospective file reading across health and social care Carers annual survey Training Needs Analysis Moray 8 pillars Use of IORN2 dependency tool

18 Headlines from our benchmarking 317 individuals with dementia 66% were female, 34% were male Almost half (159)were living in a care home Most were in the and age groups There were 451 emergency admissions 37% had multiple emergency admissions Multi morbidity is common Many Carers of people with dementia are over 65

19 What progress have we made? Steering group and DPC sub group established and meeting monthly 5 GP s funded and commenced on dementia scholarship Course Training Needs analysis complete Identification of DPC s 20 individuals identified who will have a DPC GP s and Consultants informed of involvement of their patients letter Commenced data measurement on 1/10/14 Evolving change package and measurement plan

20 Dementia Practice Co-ordinators Sub group established meets monthly Community Psychiatric Nurses, SW advanced Practitioners, District Nurses, Specialist nurse, Community Hospital charge nurse, Day Care Workshop to focus on communication and Clarify referral pathways across the 8 pillars Promoting Excellence Framework identify training needs Develop/ agree a recording tool of activity and interventions with the individual Verbal agreement with 20 individuals/carers, letters out Completion of IORN2 dependency Tool for individuals commenced Develop DPC information Pack

21 Challenges and Learning Complexities of 8 Pillars Model multi-professional input around them and clarity about the access and the pathways to them Engaging with Primary Care Competing priorities integration, winter pressures DPC role enhanced level Data gathering and measurement Measuring personal experience Carer involvement is key

22 Next steps Joint event between Moray and Highland test sites shared learning Plan follow up interviews - experience measures Continue recording the activity and interventions delivered spread sheet submission Explore dementia friendly communities in Moray