Paving the way in dementia diagnosis: Lessons learnt for future planning 28 April 2015

Transcription

1 London Dementia Strategic Clinical Network Paving the way in dementia diagnosis: Lessons learnt for future planning 28 April 2015 Date

2 Mental Health of Older Adults and Dementia Clinical Academic Group Dementia care pathways and diagnosis rates lessons learned from the London CCGs Dr Daniel Harwood Consultant Psychiatrist and London Dementia Ambassador NHS England

3 This talk Mental Health of Older Adults and Dementia Clinical Academic Group The 67% ambition and London s rise to the top What s made the difference? What makes a good dementia care pathway? The future

4 NHSE 2014/15 Plan for Dementia Mental Health of Older Adults and Dementia Clinical Academic Group Regional and Area Team Support to CCGs Improving Data eg harmonisation of clinical records Proactive Communications Intensive Clinical Support (Ambassadors) Enhanced services

5 NHSE Diagnostic ambition Mental Health of Older Adults and Dementia Clinical Academic Group NHSE set a diagnostic ambition of 67% of people with dementia were to be diagnosed and on GP QoF Case Register by April 2015 current London rate (March figures) is 65.79%- the highest rate of all English Regions 14 CCGs now have reached the two-thirds ambition A further 7 are over 60%

6 Dementia Diagnosis Rates /15 - Organisation Name April April May May June June July July August September October November December January February March Movmt in in Movmt in in last last month last last year year Mental Health of Older Adults and Dementia Clinical Academic Group NHS NHS Harrow CCG CCG NHS NHS Havering CCG CCG NHS NHS Croydon CCG CCG NHS NHS Kingston CCG CCG NHS NHS Hillingdon CCG CCG NHS NHS Sutton CCG CCG NHS NHS Bexley CCG CCG NHS NHS Bromley CCG CCG NHS NHS Wandsworth CCG CCG NHS NHS Redbridge CCG CCG NHS NHS Enfield CCG CCG NHS NHS Lewisham CCG CCG NHS NHS Ealing CCG CCG NHS NHS Richmond CCG CCG NHS NHS Barking && Dagenham CCG CCG NHS NHS Haringey CCG CCG NHS NHS Lambeth CCG CCG LONDON AREA TEAM NHS NHS Merton CCG CCG NHS NHS Barnet CCG CCG NHS NHS Hammersmith and and Fulham CCG CCG NHS NHS Newham CCG CCG NHS NHS Southwark CCG CCG NHS NHS Camden CCG CCG NHS NHS Greenwich CCG CCG NHS NHS Hounslow CCG CCG NHS NHS City City and and Hackney CCG CCG NHS NHS Waltham Forest CCG CCG NHS NHS Brent CCG CCG NHS NHS Central London (Westminster) CCG CCG NHS NHS West London (K&C && QPP) CCG CCG NHS NHS Tower Hamlets CCG CCG NHS NHS Islington CCG CCG

7 The rise in London Diagnosis Rates Mental Health of Older Adults and Dementia Clinical Academic Group

8 What s made the difference? Mental Health of Older Adults and Dementia Clinical Academic Group Data harmonisation and coding Specific initiatives care home projects, short term funding of posts A general increased awareness Permission for GPs to make a diagnosis and start treatment A review of care pathways and a re-think of accepted practice

9 Five Year Forward View Mental Health of Older Adults and Dementia Clinical Academic Group Prevention and public health Patients having far greater control Prevention and public health Break down barriers between primary/secondary care Multispecialty Community providers Primary and Acute care systems New deal for GPs Parity of esteem Local leadership

10 What makes a good dementia care pathway Mental Health of Older Adults and Dementia Clinical Academic Group Public health approach understanding your local population eg BME groups GPs GP clinical leadership coding and data harmonisation Support for more primary care based initiatives Memory Services commissioned to provide what s needed locally monitored with demand/capacity analysis

11 What good dementia care looks like - service level Mental Health of Older Adults and Dementia Clinical Academic Group Joined up care a person (and their carer), wherever they are diagnosed, should have access to all available services, and join a clear pathway Post-diagnostic interventions should be individualised and person-centred Strategies to address needs of specific populations Care homes People with long term conditions at home General hospital

12 The future for dementia services Mental Health of Older Adults and Dementia Clinical Academic Group More diagnosis and treatment in primary care Plug the gaps where diagnosis rates are lower Care homes Long term conditions Socially isolated/disconnected groups Properly integrated support Memory services responsive and more integrated with primary care easier access to advice/ consultation Better post-diagnostic support services

13 Future priorities for NHSE Mental Health of Older Adults and Dementia Clinical Academic Group Continued focus on improving diagnosis but new more accurate CFAS prevalence figures used as denominator instead of DPC. And no change in target! Post-diagnostic interventions will be main focus this year Treat dementia as a long- term condition analogies with diabetes care More focus on Local Authority/ voluntary/primary care services Care homes

14 Things to read Mental Health of Older Adults and Dementia Clinical Academic Group Dementia diagnosis and management- a brief pragmatic resource for GPs, NHSE Diagnosing dementia in care homes

15 Why GP Leadership is needed in Dementia Care Dr Nerida Burnie GP, Kingston CCG

16 Dementia Diagnosis Rate Challenge April 2014 Kingston CCG 42.53% Memory service not commissioned separately from the CMHT for older persons service. Dementia advisor post funding not consistently available Aging community Anticipated increasingly diverse population

17 Action plan Hearts and Minds campaign for primary care raise awareness amongst clinicians Increase diagnosis rates by coding clean up exercise ( supported) Look to streamline access to memory assessment reduce waiting times Increase support from 3 rd sector Plan to establish Community memory service medium to long term

18 Hearts and Minds Campaign Presentation to the CCG Council of Member s meeting Presentation to the Practice Nurse Conference Offered lunch time education meetings for any practice. Distribution of the Primer on Dementia in primary care to all practices 2 page Dementia Key facts for GPs including coding info and guidance on assessment

19 Pilot to strengthen links with primary care and 3 rd Sector Funding secured from the Better Care Fund to arrange a pilot. Dementia Information Officer from Alzheimer s society Primary role to liaise with primary care

20 Coding Improvement Promoted the coding clean up exercise to all practices. Funded 2 staff to go out to each practice and complete the audit for them. Next stage possibly going into care homes

21 Dementia diagnosis rate Kingston CCG April % Kingston CCG April %

22 Role of GP Leadership Why do we need it? So many pressures on Primary Care clinicians competing interests Raise awareness by making a good case for the clinical improvement which can be achieved for patients Financial incentives?

23 Importance of a good pathway Good dementia services Responsive services Capacity Good communications between primary care and dementia services

24 Problem of capacity? Demand increase With increased awareness in public Increased awareness in health care and clinicians Awareness of advantage to timely diagnosis and the huge stress of delays in diagnosis Pressures to improve diagnosis rate Potential problem Possibility of increased numbers of patients looking for assessment and diagnosis How can memory services not be overwhelmed by referrals ( some not always appropriate / necessary)

25 Should GPs be making the diagnosis of Dementia? Advantages Patients are well known to their primary care clinicians They are see regularly in primary care Longitudinal assessment can be made Disadvantages Lack of specialist input into the assessment Concerns about appropriate clinical experience Time needed for assessment

26 Making the diagnosis Stage 1 Exclude other causes for symptoms Think the 4 D s: Delirium; Depression; Drugs; Dementia Progressive symptoms, causing negative effect ADL Stage 2 Determine cause / subtype of dementia Alzheimer s disease Vascular dementia Lewy body

27 Making the diagnosis Any clinician with appropriate skills can recognise and make a diagnosis of dementia once established Comprehensive assessment history, collateral history, physical examination, mental state examination, a specific assessment of cognitive function and selected investigations

28 Specialist assessment? Very early stages of dementia Atypical presentation Perhaps needed to establish the exact cause / subtype Younger patient People with learning disabilities

29 Cases GPs could diagnose Consider nursing home Why is it important to make the diagnosis? Could memantine or cholinesterase inhibitors help? Review of medication - may find some medication which would be helpful to stop Recognising diagnosis may help social care staff and health care professionals involved

30 Diagnosing those in care homes Care staff may alter care plans to account for the cognitive impairment Exploring levels of diagnosis in care home may highlight training needs for care staff Diagnosis can be used as trigger in care home to discuss advanced care planning including when not to admit to hospital Relatives may find a formal diagnosis helpful to understand changes and to anticipate future changes Good local data on prevalence can help service planning

31 How to diagnose in care home Review of care home patients and discussion with care home staff is likely to highlight any patients without formal diagnosis but who may have dementia Usually no need for secondary care to make this diagnosis unless unusual symptoms Think about dementia diagnosis when new patient is admitted to home. Good opportunity to make appropriate plans for current and also anticipatory care

32 Diagnosing dementia in primary care GPs should be encouraged to make the diagnosis in straightforward cases if they are confident and happy to do so. E.g. if they are an older person with a typical picture of Alzheimer's disease

33 What is needed for this to happen? Good, prompt access to memory service for support and advice on individual cases e.g. by phone, , by sitting along side memory clinic etc Robust and effective post diagnostic support for the individual and carer. Access to appropriate investigation, imaging and interpretation of results as needed Training, support, advice, mentorship from memory service as needed

34 Primary care strengths GPs are still generalists and truly able to holistically assess patients. They can consider the impact of various co-morbidities on the patient with dementia and usually know their patient well. Variety of experience, interest, skills and training amongst GPs Not all GPs are equipped to provide complex care in all specialties but many have special interests in some Diagnosing dementia in primary care should not be discouraged if the skills and interests exist in clinicians The challenge is to allow this to happen safely and effectively for the benefit of patients

35 The Redbridge Story A primary care engagement project in increasing dementia diagnosis rate whilst enhancing quality of life and post diagnosis support Dr Chidi Okorie Dementia Clinical Lead 28 April 2015

36 Redbridge CCG serves a diverse population of over 280,000 residents via 46 GP practices, acute and community based health care services The population of adults aged 65+years is projected to increase by 10% (3400 people) by 2020, with the greatest increase in the age group years (projected 23% increase) Increasing dementia diagnosis rates, whilst optimising post-diagnosis support, has been a high priority for the CCG via building positive relationships with our practices, local partners and service providers.

37 Looking back. March 2014 Dementia diagnosis rate: 48% Number of patients on QOF Register: 1246 Average days from GP referral to assessment at memory clinic: 21 days Average days from assessment to diagnosis: 20 weeks Memory clinic diagnosis rate: 46%

38 What did we do? The Improvement Plan Dementia Partnership Board with all the local partners Development of a three year Dementia Action Plan Intense engagement work with 46 GP practices Intense pathway work with NELFT Memory Clinic Dementia Bridge Builders Project via London Borough of Redbridge Data Cleansing through coding exercise and SUS to QOF data harmonisation DES one to one support to practices Data benchmarking at practice, locality, borough, London, national levels NHSE funded Care Home Project (132new potential dementia patients identified in 4 weeks) Strengthened post-diagnosis support via Alzheimers Society and AGE UK.

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40 Dementia Diagnosis Rate

41 Number of patients on QOF register

42 Average number of days from GP referral to assessment at Memory Clinic

43 Average number of weeks from assessment to diagnosis

44 Memory Clinic diagnosis rate

45 Highest ranked practices - % increase April 2014 to March % 33.54% 30.33% 23.84% CHADWELL HEATH SURGERY RODING LANE SURGERY ST CLEMENTS SURGERY THE EASTERN AVENUE MEDICAL CENTRE

46 Conclusions: Building strong empowered relationships and developing personalised actions plans with each practice based on their own data and needs brings positive results to both patients and the CCG Sharing benchmarked performance data at locality committee meetings creates competition and ambition to improve Approaching the project as a quality initiative rather than a target driven motive brings extremely positive results Positive outcomes for patients can only be achieved as a collaborative approach by all partners including patients and carers.

47 Next steps: Keep the positive momentum and energy amongst practices via further training, personalised support and data benchmarking Evaluate the outcomes from the care home project and focus on care home staff training Further enhance the memory clinic pathways to reduce waiting times and ensure post diagnosis support is offered to every patient/carer Continue with strict monitoring of diagnosis rate monthly at practice, locality, borough and London level Remain committed to achieving the 67% national target in 2015/16

48 Increasing the identification and diagnosis rate of people with dementia in Brent Dr MC Patel Clinical Director leading on dementia NHS Brent CCG

49 Starting point Meeting the target Next steps Target 67%, actual 48.7% diagnosis rate of prevalent population GP incentive scheme Well established care-pathway (right) Identification and referral to the specialist Memory Clinic Follow-up by GP 6 months after discharge 48.7% diagnosis of prevalent population (2,367) Dementia care pathway Primary Care Dementia Nurses bridge Memory Clinic and primary care on discharge Steering Group CCG Clinical Director GPwSI in dementia Memory Clinic psychiatrist and service manager

50 Starting point Meeting the target Next steps GP incentive scheme Quantified data gap (see chart) 512 new cases in 2013/14 Only 106 QOF increase Dementia care pathway GP role changed to diagnose undifferentiated dementia Steering Group Membership extended to include voluntary organisations representing patients and carers Coordinated response to: IT questions - centrally developed EMISweb query to help re-coding Clinical questions - technical clinical guidance on diagnosis by GPs Ethical questions - patients and carers championed the benefits of diagnosis

51 Starting point Meeting the target Next steps GP incentive scheme Quantified data gap (see chart) 512 new cases in 2013/14 Only 106 QOF increase Dementia care pathway GP role changed to diagnose undifferentiated dementia Steering Group Membership extended to include voluntary organisations representing patients and carers Coordinated response to: IT questions - centrally developed EMISweb query to help re-coding Clinical questions - technical clinical guidance on diagnosis by GPs Ethical questions - patients and carers championed the benefits of diagnosis

52 Starting point Meeting the target Next steps Target 67%, achieved 70.7% diagnosis rate of prevalent population GP incentive scheme Embed learning Continue monitoring Data analyst support for identified practices (3 of 67 did not submit returns) Dementia care pathway Re-commission pathway (see right) Primary Care Dementia Nurses to be a resource in primary care, supporting more patients and carers Steering Group Targeted identification work with: nursing homes under-represented communities Work with voluntary sector on follow-up support

53 London Dementia Strategic Clinical Network Dinner Networking Date

54 Increasing the dementia diagnosis and post diagnosis support in Richmond Aileen Jackson Joint Commissioning Collaborative Richmond CCG and LA Joint Commissioning Collaborative

55 December 31st 2014 Diagnosis rate 54.8% Need to diagnosis additional 246 patients READ code exercise completed in 2013/14 2 x GP education dementia education sessions Offer of support to GP practices with low % rates. Recognised good support services Slow upward trend, little chance of achieving 67% Joint Commissioning Collaborative

56 Dementia Support Services Dementia advisor Day Services Shared Lives respite service Telecare promotion Carers Hub Service Community Independent living service Support Service for younger people with dementia and carers Richmond Dementia Action Alliance Joint Commissioning Collaborative

57 March 31 st % dementia diagnosis Predicted 65% + by June 30 th Joint Commissioning Collaborative

58 Joint Commissioning Collaborative

59 GP Dementia Champion project Invite to bid for NHSE funding Employment of a GP to enter all care and nursing homes to assess residents who show signed of cognitive impairment Support to all GP practices by completing dementia list validation exercise Distribution of letter and support to people assessed and their carers ( family and friends) Joint Commissioning Collaborative

60 Methodology MH trusts and trust who specialised in LD asked for diagnosis data All GPs and care homes asked to particiapte in Dementia GP champion project 29 out of 30 GPs practices participated CH 25 out of 30 practices in list validation Used opportunity to trial SLHIN Care home case finding tool. Barbara s Story Training Joint Commissioning Collaborative

61 Overview of results 175 assessments of people took place in care homes where memory /confusion was a concern 69 new diagnosis with dementia (AMTS < 5) 42 referrals to memory clinic (AMTS 5-7) 97 new patients coded through list validation exercise Total of 166 ( 208 with MC ) Joint Commissioning Collaborative

62 Diagnosis - by size of care home Referrals to memory clinic new diagnosis by care home Joint Commissioning Collaborative

63 100% Graph X: Percentage of residents already diagnosed, diagnosed as part of project or referred to memory service 90% 7% 80% 70% 60% 50% 40% 30% 20% 95% 7% 29% 14% 57% 64% 4% 4% 73% 12% 22% 37% 17% 8% 46% 2% 12% 55% 10% 59% 7% 6% 52% 8% 18% 12% 6% 35% 38% 13% 4% 7% 44% 44% 6% 6% 6% 9% 38% 36% 7% 10% 10% 0% 13% % already diagnosed prior to project % diagnosed as part of project % referred to memory service Joint Commissioning Collaborative

64 Care Home diagnosis by GP practice Joint Commissioning Collaborative

65 List validation exercise by GP practice Joint Commissioning Collaborative

66 Sustainability Circulate GP Dementia Champion evaluation report MH investment money to create 2 new dementia clinical nurse specialists GP education through CEPN GP LCS to include Memory assessments New format Memory Clinic letters to GPs, copies to care home, quarterly lists to GPs. Promotion of the Health Innovation South London dementia case finding tool in Richmond Care Homes Joint Commissioning Collaborative

67 Meeting the Dementia Diagnosis and Future Plans Clare Charlton, Joint Health Commissioner Older People Caroline Chant Joint Commissioning Manager Older People 28 th April 2015 Local clinicians working with local people for a healthier future 67

68 Barnet Second highest number of older people over the age of 65 in London Currently estimated 4371 people with dementia in Barnet By 2021 estimated increase of 24% Barnet has the highest number of care homes registered for dementia in London 108 for older people Barnet Diagnosis rate 67.7% (March 2015) Local clinicians working with local people for a healthier future

69 Dementia in Barnet LBB and BCCG working together with key partners An existing network of services joined by newly commissioned services, including: BCCG - Remodelled Memory Assessment Service (MAS) LBB investment in wellbeing, prevention, support to carers, (Dementia Advisor service, Dementia café s) Barnet Dementia event/training DIS 50% take up from GP s Dementia Diagnosis Rate October November December January February March Dementia Diagnosis Rate Local clinicians working with local people for a healthier future

70 Dementia Coding Project Initially sent out coding guidance from NHS England Engaged with Primary Care GP IT Project Manager to develop bespoke Barnet Query Tested and redesigned, retrial in five practices Communications: GP Bulletin GP Intranet Sent direct to practice managers Followed up with phone calls to PMs with practices with highest gap GP IT PM visited practices to run the Barnet EMIS Query 65 practices Medicines Management Pharmacists ran medication query at practices and assisted with new READ codes 34 practices MAS Senior Nurse visited 4 practices with longer review lists MAS sent out lists of patients they had diagnosed with the ICD10 and READ codes for practices to directly update records Using funding: Paid practices incentive fee to update their records by 31/3/15 Local clinicians working with local people for a healthier future

71 Future Steps Barnet Dementia Manifesto 75% by 2017 Developing plan to take us to 75% Dementia Diagnosis Rate MAS commencing START carers workshops Increasing Dementia Advisors to x 3 Awareness raising with all partners: MAS, Alzheimer s Society, LBB, NHS New GP Leads in place: Dr Sharon Lawrence and Dr Sanchita Sen Working with Barnet Healthwatch Continue dementia training for GPs, Pharmacists, HCAs and Council Staff Working with GP Leads regarding Care Home Support Local clinicians working with local people for a healthier future

72 Thank You for Listening Clare Charlton Joint Health Commissioner London Borough of Barnet & Barnet CCG Caroline Chant Joint Commissioning Manager London Borough of Barnet & Barnet CCG Local clinicians working with local people for a healthier future

73 London Dementia Strategic Clinical Network Feedback and Next Steps Date

74 London Dementia Strategic Clinical Network Date Close Thank you for coming