Dementia Advisors. Service Specification. Draft v 6.0

Transcription

1 Dementia Advisors Service Specification Draft v 6.0

2 CONTENTS 1. Purpose of the service Key service outcomes: Aims and objectives: Scope Service users Equity of access to services Geographical coverage/boundaries Referral sources Structural location of service Days/hours of operation Service delivery high level care pathway Mapping local and universal assets Managing Referrals Identifying needs and personal outcomes Recording information Follow up Making outward Referrals Managing budget for carers breaks: Evaluation... 9 a) Outcomes:... 9 b) Key Measures:... 9 c) Methods d) Resources e) Timescales Appendix A Dementia Advisors Service Flowchart... 0 Appendix B Dementia Advisors Visit Summary (sample)

3 1. PURPOSE OF THE SERVICE Dementia is one of the major health problems facing health and social care services. There are currently 750,000 people in the UK living with dementia and it is estimated that the number will double over the next 40 years. Currently, around two thirds of people with dementia never receive a formal diagnosis. Those who have been diagnosed get very little support from health and social care until their need is so great that they are near or at crisis and eligible for Community Mental Health Team or social care support. The Dementia Advisors service has been set up to address this gap in provision and support people with dementia and their carers before to help prevent the crisis. Dementia Advisors will provide personalised, non-clinical emotional and practical support and advice to people diagnosed with dementia and their carers registered with a South Gloucestershire GP. Each of the Dementia Advisors will work across one of South Gloucestershire GP clusters to provide a highly responsive and personalised support to people with diagnosis of dementia and their carers registered with practices in the cluster. The service will be provided in 3 out of six clusters. NB To ensure equal access to support in other areas of South Gloucestershire Sirona is working in partnership with Alzheimer Society and Cluster 5 who will provide similar dementia support service from the outstanding 3 clusters. 2. KEY SERVICE OUTCOMES: The desired outcomes are as follows: People with dementia and their carers feel well supported and informed; People with dementia and their families know who to contact to access information, services and support; People with dementia and their carers feel more confident and are enabled to live independently. People with dementia and their carers feel less isolated and lonely and more connected with their local communities Support is tailored to meet the needs of the person with dementia, in partnership with any carer; Carers get support and breaks, especially in emergency situations; People living with dementia are signposted to mainstream services and support, as appropriate Greater awareness of dementia across health and social care and wider society. 3. AIMS AND OBJECTIVES: The overarching aim of the Dementia Advisor service is to deliver a highly responsive and personalised emotional and practical support to people with diagnosis of dementia and their carers. The objectives of the service are to contribute to the whole multidisciplinary approach to cluster based care delivery in order : provide structured support to the referred individuals including an initial referral appointment and follow up as required throughout the person s life with dementia. 2

4 co-develop with the person with dementia and their immediate carers, families and supporters an agreed wellbeing plan. help people to navigate and access appropriate services, ensuring that they are able to make contact with the right person for help, and helping them to do so as necessary, either personally or by arranging an appropriate referral develop a network of support from health and care professionals and providers in the cluster who will refer people with a diagnosis to the service at the earliest opportunity. ensure that the service is readily accessible and meets the range of needs of the local population, including minority groups be present and involved in local cluster based dementia groups and activities to promote the service and to identify individuals who could benefit from it. ensure continuity of care across the pathway and integration with other care providers ensure that the service is delivered in a considered, timely and co-ordinated manner This will assist the CCG to achieve the following national standards: Improving our local contribution to making every contact count and meeting a significant need for information and support not provided by other services (Mandate 3 Preventing ill health and improving access to treatment); Providing an opportunity to give people with this long term condition a holistic, personalised care plan (Mandate 4 Supporting people with long term conditions); Contribute to the achievement of the Better Care Fund target to reduce non-elective admissions and providing a bridge between primary and community care, social care and mental health services (Mandate 7 - Integrated Care); Improve support before and at crisis for people with dementia and any carers (Mandate 11 Parity of Esteem and Mandate 13 Safeguarding vulnerable people) Help people with dementia and any carers to self-manage from the point of their diagnosis (Mandate 14 Quality of Care, especially older people). 4. SCOPE 4.1. SERVICE USERS The Dementia Advisors service is designed to support adults of all ages with symptoms of mild to moderate dementia who have already received a diagnosis and are not eligible for Community Mental Health Team or social care support. The support is also provided to the carers, offering emotional and practical support and providing short breaks opportunities to avoid crisis. The service is offered to individuals registered with a general practice in one of the three participating cluster areas EQUITY OF ACCESS TO SERVICES This service is accessible to all eligible individuals, regardless of age, disability, gender reassignment, race, religion or belief, sex or sexual orientation GEOGRAPHICAL COVERAGE/BOUNDARIES The service is provided to people registered with general practitioner across three out of six GP clusters: 3

5 Cluster 1: GP Surgeries: Foubister, St Marys Street Surgery, Almondsbury Surgery, Pilning Surgery, Thornbury Health Centre Cluster 2: GP Surgeries: Bradley Stoke Surgery, Coniston, Concord, Northville, Stoke Gifford and Conygre Cluster 3: GP Surgeries: Courtside, West Walk, Kennedy Way, Wellington Road NB As described in section 1 a similar approach will be provided in cluster 4, 5 & 6 by Alzheimer Society and Cluster 5 by Sirona 4.4. REFERRAL SOURCES The service will accept referrals from: General practitioners Social Care Community health practitioners Individuals and their carers Older Adults Community Mental Health Team (CMHT) Other services The referrals will generally go through to Yate Locality Office however on occasions Dementia Advisors will accept direct referrals from the individuals and professionals. The service intends to maximise joint working opportunity and liaison with primary care, secondary care and voluntary sector, contributing to the local health and care integration agenda by connecting the disintegrated support for people with dementia into one seamless support system. Clusters: The service will be aligned with the local clusters strengthening the cluster working arrangements that are being introduced as part of the Better Care Cluster Integration project. General Practices: Dementia Advisors will work closely with the general practices, identifying eligible individuals, accepting referrals and liaising with the general practitioners as appropriate. Social Care: Dementia Advisors will liaise with social care team, accepting referrals and referring eligible individuals Active Ageing: Dementia Advisors will be line managed by Health Visitors within the Active ageing service and will receive and direct referrals as appropriate. Active Ageing will offer guidance and support to dementia advisors who will work in parallel with the health visitors. Falls service (Sirona): Dementia Advisors will be working closely with the falls service where appropriate. 4

6 Community Connectors: Dementia Advisors will work with Wellbeing Workers in each GP cluster to identify opportunities and support available to the individuals in their area and enable individuals to access it Alzheimer s Society: Dementia Advisors will work alongside Dementia Support Workers provided by the Alzheimer s Society, exchanging knowledge, best practice and peer support Dementia Nurse Cluster 5: Dementia Advisors will work alongside Dementia Nurse operating in Cluster 5, exchanging knowledge, best practice and peer support AWP Memory Service: Dementia Advisors will liaise with AWP s Memory Service as appropriate Older Adults CMHT: Dementia Advisors will have an on-going working relationship with the CMHT around individual pwd/carers. Referring people and families onto CMHT when risk is too high for DAs to manage, taking people back when crisis resolved/ situation settled. Other services: Dementia Advisors will liaise with other relevant services as appropriate 4.5. STRUCTURAL LOCATION OF SERVICE A Dementia Advisor will be located each in each of the three identified clusters. The will be lined managed under the Active Ageing structure. Sue Parris remains the accountable service lead DAYS/HOURS OF OPERATION Dementia Advisors will operate across 30 hours per each week, between Monday and Friday, with occasional evenings. 5. SERVICE DELIVERY 5.1. HIGH LEVEL CARE PATHWAY The flowchart on the next page illustrates high level care pathway. For detail process mapping please see Appendix A at the end of this document. 5

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8 5.2. MAPPING LOCAL AND UNIVERSAL ASSETS Dementia Advisors will be responsible for mapping local support offer for people with dementia and carers, including statutory services but also support groups, memory cafes, physical activities, interest groups, advocacy support, advice centres but also potential local and charitable funds. Each dementia advisor will keep an electronic record of the local offer for their clusters, update it regularly and cross reference against the Well Aware website to make sure the later is also up to date. If any activities are identified as missing from the Well Aware or needing an update, an will be issued to Well Aware team with the new / updated data. Dementia Advisors will work closely with the health visitors and the Community Connectors scheme (Wellbeing Workers) to map local assets. The local support offer will be used to help to signpost people to the appropriate support, ensuring they have all the information needed, e.g. accessibility, cost, or eligibility MANAGING REFERRALS Most referrals to Dementia Advisors will be triaged by the Yate Locality Office. Locality office will forward the referral to the Dementia Advisors within one working day via EMIS. Self-referrals from the individuals may also be accepted, subject to the eligibility criteria listed in section 4.1. Direct referrals may be identified during sessions in dementia cafes and other dementia related events, and community activities that Dementia Advisors will attend. Direct referrals from other professionals will also be accepted, subject to eligibility criteria outlined in this document. Such referrals may take place where strong relationships have already been developed between the health and care professionals and Dementia Advisors or where the person is already known to the Dementia Advisors. Dementia Advisors will respond to the referral within 3 working days, ensuring the individuals are contacted in those 3 days. Dementia Advisors will contact referred individuals by phone and arrange the appointment within 5 working days unless indicated differently by the referred person. This may be followed up with a letter IDENTIFYING NEEDS AND PERSONAL OUTCOMES Each visit to the referred individual should focus primarily on providing the individual and their carer with opportunity to talk about their concerns, needs and aspirations. The Dementia Advisor will guide the conversations to make sure the following areas are covered: The person their story, their interests, their concerns and hopes The carer as above Family / friends and social life to assess the social assets / support network available Home assessment of the living environments, looking out for risks and hazards, and improvements and assistive technology that could help to improve the wellbeing Food & Eating find out about diets, if the person is eating regularly, if they need help with shopping, check for continence problems Activities identifying any physical and mental activities that person undertakes or what would be the person interested in undertaking Aims and priorities what support the person and their carer want to improve, change or reduce to increase their wellbeing, what support may dementia advisor offer or who could help 7

9 Additionally to the guided conversation the Dementia Advisors will complete a checklist designed by the Falls Service, based on the environmental assessment. Dementia Advisors will also help the person and their family to identify solutions to maximise their income, signposting to grants and awards, blue badges, diamond cards, can t wait cards, carers cards, etc 5.5. RECORDING INFORMATION The key information will be captured during the visit on a guided conversation sheet the information will be then transferred onto EMIS after the visit. Dementia Advisors will also complete a short handwritten Visit Summary that they will share with the person at the end of the visit (Appendix B) 5.6. FOLLOW UP Dementia Advisors will follow up the visit if appropriate. The details of the follow up depend on the individual circumstances and the agreed action plan. Follow ups could include: - Referral - Visit - Telephone contact - Dementia Café / dementia activity participation 5.7. MAKING OUTWARD REFERRALS The referrals to other agencies and services will be sent out by post, EMIS tasking or CSO desk for social care. EMIS record will be update to notify that the referral has been done. A follow up with the person to ensure they have received the support may take place MANAGING BUDGET FOR CARERS BREAKS: A carers emergency break budget will be available to allocate for carers in urgent need of a respite break. This offer, unlike the carers breaks offered by council, will not require a formal Carers Assessment. However a process will be agreed to allocate the budgets and each case will be considered on an individual basis. The dementia advisors will not hold the budgets but they will request based on their assessment of the carers situation. The budgets should be used for respite break only and when the need is seen as urgent TRAINING AND INDUCTION In the first month of their appointment, Dementia Advisors will receive comprehensive training and induction allowing them to learn about different aspects of dementia as a condition, living with dementia and caring for people with dementia. The training will also include aspects of learning about falls, continence issues and some of the dementia co-morbidities. Each dementia advisor will also be offered completion of City and Guilds Dementia Care qualifications level 2 and 3. 8

10 Some of the training needs may be identified in course of the pilot and all efforts will be made to ensure these needs are fulfilled. A part of the induction process dementia advisors will be meetings with key commissioners and providers of dementia related services, including Memory Service, Older Adults CMHT, Alzheimer Society. 6. EVALUATION 6.1. OUTCOMES: People with dementia and their carers feel well supported and informed; People with dementia and their families know who to contact to access information, services and support; People with dementia and their carers feel more confident and are enabled to live independently. People with dementia and their carers feel less isolated and lonely and more connected with their local communities Support is tailored to meet the needs of the person with dementia, in partnership with any carer; Carers get support and breaks, especially in emergency situations; People living with dementia are signposted to mainstream services and support, as appropriate Greater awareness of dementia across health and social care and wider society KEY MEASURES: This is a test and learn project and in the course of delivering the service the following key information will be captured and used as future indicators of performance: Number of referrals to Dementia Advisors Number of individuals seen by Dementia Advisors Number of individuals who declined the service of Dementia Advisors Number of follow-up contacts: face to face and not face to face. Number of referrals made: o Memory team o Falls service o Third sector support o Carer support center o Social care o Other Number of contact made at: o Persons home o Dementia Café meeting o Other event 9

11 o Other place Number of requests for carers emergency break fund Number of carers emergency break funds allocated 6.3. METHODS The key information / measures will be captured through EMIS recording system The qualitative outcomes will be captured via case studies and service users surveys 6.7. RESOURCES Gemma Morgan will be responsible for the design of the evaluation; The evaluation process will be led by Thomas George from Public Health, South Glos Council (line managed and supervised by Rachel Clark) 6.8. TIMESCALES The pilot is to run for a year (from 18 th of July 2016 to 18 th of July 2017) Dec Initial review of the performance and outcomes is needed by December 2016, to request extension of contract to be ready by December Dec Full service evaluation enabling the service to re-apply for the funding needs to be ready by December

12 APPENDIX A DEMENTIA ADVISORS SERVICE FLOWCHART

13 APPENDIX B DEMENTIA ADVISORS VISIT SUMMARY (SAMPLE) Ann s Dementia Advisor Visit Sheet Name: Carer: Dementia Advisor: Ann Smith John Smith Fiona Willows Telephone: Date of Visit: My Needs and Goals: - Ann would like to paint again - John needs to be able to leave Ann for an hour per week to go shopping - New shower rail can t afford at the moment - Both need information about benefits available - John is worried about his blood pressure tablets he feels drowsy and sleepy during the day 2. My Plan: - Fiona will refer to Social Care for personal care budget to fit new shower rail & hire an art tutor - Fiona will look for local art classes and private art tutors and check accessibility - Fiona will refer to Age UK who provide Ann and John with benefits advice - Fiona to speak to John s GP - Dr Proper - Follow-up phone call agreed next Monday at 12:00 am