REPORT TO CLINICAL COMMISSIONING GROUP

Transcription

1 REPORT TO CLINICAL COMMISSIONING GROUP 12th December 2012 Agenda No. 6.2 Title of Document: Report Author/s: Lead Director/ Clinical Lead: Contact details: Commissioning Model for Dementia Care Dr Aryan Lawe, GP Lead for Dementia Gill Thompson, OAMH Project Manager Lucie Waters, Director of Commissioning and Planning Dr. Aryan Lawe, GP Lead for Dementia Summary: This report presents the five tier commissioning model for dementia services Key sections for particular note (paragraph/page), areas of concern etc: The key section of the report is the Dementia Commissioning Model (2.), noting the outcomes of the model (2.2), the five tier model of care for dementia (2.3) and referrals between these tiers (2.5). Equality Impact Assessment Has an EIA been carried out? (If not, state reasons) YES Key issues from assessment The initial EIA undertaken notes the demographic changes anticipated over the next 10 years, and sets out service provision which respond to these changes. One of the priorities is to reduce inequalities of access to memory assessment services, and to tackle the under-representation of some groups in services. An EIA undertaken for the memory assessment service showed no potential for discrimination and all appropriate opportunities to advance equality and it is the aim that the quality of service will improve by this procurement. Information Privacy Issues Has a consideration of privacy impacts been undertaken and controlled for? Yes Key issues from assessment No issues were highlighted and all information governance controls were monitored and managed by both the Project Board and Older Adults Mental Health Clinical reference Group. 1

2 Please state which of the following priorities/objectives this document links to or provides evidence for: PPI: QIPP Plan: N/A Operating Plan: Ensure improvements in general practice and community services including improvement of diagnostic rates Reduce inappropriate antipsychotic prescribing Ensure provider compliant with NICE quality standards for dementia Workforce: Corporate Objectives/Risks: Financial Implications: Potential double funding of future memory assessment service in tier two due to GPs referring to multiple providers instead of single contracted route (as defined by the tiers). Recurrent funding is to fund the whole dementia pathway with the five tier model of care reliant upon efficiencies being made in other service functions to fund services across all the tiers Super Locally Enhanced Service being utilised to incentivise GPs to adopt the clinically approved dementia pathway meaning demand could rise above levels forecast for in tier one. Acute CQUIN is setting up a service to screen patients admitted who are 75 and over which could impact on the number of new cases referred to tier two Reviewed by: Recommendations: To approve the commissioning model for dementia care To note the specification development and proposed work programme for dementia in Committees that have previously agreed the report: Clinical Reference Group- 14 th November

3 1. STRATEGIC DRIVERS 1.1 National Context The National Dementia Strategy, Living Well with Dementia, was published in February The strategy outlined a 5 year plan containing 17 objectives to improve the services for people with dementia throughout their lives from before diagnosis until end of life. The full set of NDS objectives can be found online at ce/dh_ The Strategy identifies 17 key objectives which, when implemented at a local level, should result in significant improvements in the quality of services provided to people with dementia and their carers and /or families. The implementation of this strategy should promote a greater understanding of dementia and more importantly a catalyst for a change in the way that people with dementia are viewed and cared for at a local level. National policies that are also relevant to commissioning a memory assessment service for the early identification and care of people with dementia in Wandsworth include: Quality Outcomes for People with Dementia (DH, 2010) The NHS in England: Operating Framework 2012/13 Implementation of NICE clinical and public health guidelines. This includes clinical guideline 42: Dementia supporting people with dementia and their cares in health and social care and are the core standards that are assessed by the Care Quality Commission Our Health, Our Care, Our Say (DH, 200X) Equity and Excellence: Liberating the NHS white paper (DH, 2010) Putting People First: A shared vision and commitment to the transformation of Adult Social Care (DH, 2007) 1.2 Local Context At a local level these national policies have been interpreted to inform the strategic direction and development of Older Adults Mental Health services, which include the informal and part commissioning of a memory assessment service for Wandsworth, primarily through South West London & St George s Mental Health Trust s Older Adults Community Mental Health Teams. The following documents are key whilst developing this business case: Joint Commissioning Strategy Older People s Mental Health (NHS Wandsworth and Wandsworth Borough Council, 2008) Joint Report by the Health Overview & Scrutiny Committee report on Delivery of Mental Health services in Wandsworth for Older People. Paper 11, No 832. (NHS Wandsworth and Wandsworth Borough Council, 2011) Review of Older People s Mental Health Services in Wandsworth (Mental Health Strategies, 2011) Wandsworth Clinical Commissioning Strategy Plan & (NHS Wandsworth, 2012) Cluster Operating Plan: Older People s Services (NHS Wandsworth, 2012) 3

4 South West London & St George s Mental Health Trust (2011) Making Life Better Together Clinical Service Strategy (draft). South West London & St George s Mental Health Trust 2. Dementia Commissioning Model Local Profile The overall population profile of Wandsworth is fairly typical of London as a whole, although Wandsworth has a greater working age adult population and slightly smaller populations of children and older adults in relative terms. Population projections contained in this case were produced by the Greater London Authority (GLA). The population of Wandsworth is 287,600, with the current older age adult population (age 65+) estimated to be 24,204, accounting for 11% of the total population of Wandsworth. Over the next ten years the size the older age adult population in Wandsworth is not expected to change significantly, increasing marginally from 24,200 in 2010 to 24,400 in 2020.This represents a population increase of just 0.7% and is significantly below the London regional (9.2%) and England national figures (23%) The number of people with dementia is not predicted to change substantially over the next ten years. In fact, in contrast to most areas, the number of people with dementia is expected to fall slightly (from 1,761 in 2010 to 1,714 in 2020) due to a reduction in the > 75 population. The estimated population numbers for people with dementia in Wandsworth is 2, The estimated population is broken down into two cohorts of needs, late onset dementia in people 65 years old and over at 2,032 and under 65 year olds with early onset dementia population of 66. For each Locality in Wandsworth: Battersea, Wandle and West Wandsworth the estimated prevalence has been forecast for both types of needs at locality level. The Quality Outcomes framework (QOF) showed that 962 people had a confirmed diagnosis of dementia based on GP practice registers. This is 46% of people estimated to be living with dementia in Wandsworth, with the unmet need at 1,136 people who are currently not being diagnosed. This picture is also true regionally and nationally (London = 40% and England = 39%). Whilst Wandsworth has since a 6% increase in diagnostic rates through planned service developments managed by the Older Adults Mental Health programme in 2011 and 2012, there is still a high level of unmet need requiring improved detection and diagnosis of dementia which is a driver for the five tier model of care for dementia. 2.2 Quality Outcomes for People with Dementia and their Families A number of workshops and consultation sessions were held from June to September 2012, engaging with over 200 people including people diagnosed with dementia, carers, families, providers and professionals on the proposed dementia pathway for Wandsworth. All stakeholder engagement feedback was captured in an overarching document to inform future service development across the dementia pathway. Below is a summary of the feedback from these sessions which are now being used to generate outcomes for the dementia model of care: Early diagnosis is key and needs to be delivered quickly and effectively by appropriate specialists Communication between the services needs to be clear to reduce delays in diagnosis and treatment and inform people being diagnosed with dementia and their families 1 DH Dementia Commissioning Toolkit 4

5 Understanding my diagnosis means I can make plan for my future Support and information is available pre and post diagnosis so I can manage and live well with my dementia I am a person, one size does not fit all model of care needs to be person-centred not service focused Professionals need level of basic training on dementia to increase awareness and to offer appropriate care in all settings In addition, a group of carers submitted the following to the consultation as a summary of their needs throughout the journey of dementia: What is available? Where do we go? What can we expect? When can we expect it? 5

6 Community Nursing, Reablement, Intermediate Care and Falls Service- Delivered by Community Services Attach Dementia Commissioning Model 2012/13 TIER 0 Common theme throughout all Tiers: Patient Self Management Pre and after care support from Alzheimer s Society commissioned services i.e. groups, roles and cafes TIER 1 Essential primary care Delivered in Primary Care by General Practices Dementia register Annual review* Medicines management & 3 monthly review for patients with dementia receiving antipsychotics solely for management of behavioural and psychological symptoms in dementia (BPSD) Medication care planning and monitoring Follow up of acute episodes Provide written material on Dementia services & information on Alzheimer s Society commissioned support Referral as appropriate to specialist mental health services Physical assessments and tests as per NICE to accompany referral to Memory assessment service &Tier 3 EOLC planning - GSF * Annual & Care Plan review (inc meds) EMIS template TIER 2 Enhanced essential primary care Delivered in Primary Care by GPs with support from Community Nursing (Generic Community Services) Identify co-morbidities Hospital Avoidance: Patients at risk of admission Patients with comorbidities to have formal assessment in place and regular review (QP) to avoid emergency admissions Patients with dementia and 2 or more Long Term Conditions Professional Education Linked to improving diagnosis rates Follow up from Acute Care Discharge review TIER 3 Specialist care in the community Delivered in the community by OA CMHT service MTD assessment of health and social care needs consultant led outpatient clinics and home visits Memory assessment service Assessment and review of services funded by the Community Care Budget under Fair Access to Services Criteria MDT Care planning and case management Medication prescription & review Crisis management Advance planning Transfer of care to and from acute inpatient MH in patient units Carers assessment Distressed reactions service Day centres Therapies (ie IAPT) Carer s assessments Mental Capacity assessments Safeguarding CLDT Specialist support to generic services Discharge to Tier 1 Case Management OA CMHT (health & social care services) Community Learning Disability Teams (health and social care teams) Intermediate services/reablement TIER 4 General Hospital or Specialist Hospital based Inpatient Care Delivered in either a general hospital care setting or within Specialist Hospital based inpatient OPMH wards at Springfield Hospital General Hospital based: Acute admissions Outpatient Clinics Senior Health Medicine & Neurology Dementia screening Onward referral to Tier 3 via Tier 1 (unless urgent) Liaison Psychiatry- support clinical management of patients with mental health problems and influence arrangements Discharge back to Tier 1 Inpatient OPMH based: 24 hour acute inpatient care provision for older people with organic and/or functional mental health needs Discharge planning Transfer of care to Tier 1&3 notification Tier 1 Some patients will overlap 1,3 and 4 6

7 Tier 0 Self Management What needs to happen? Review of current self management provision to demonstrate outcomes achieved based on section 2.2 and value for money Increase in self management provision to align with the increase in early detection and diagnosis rates Improved access to existing information, education and support services for people suspected or diagnosed with dementia and their families and carers By improving and making information accessible and extending the provision of support and education this will increase awareness and understanding of dementia and mental health problems and enable people to manage and live well with dementia in community settings What will it look like? Self management for people diagnosed with dementia will be offered through third sector and voluntary organisations commissioned to provide a range of good quality and timely information about dementia, resources, rights and entitlements and local services that are available to support people diagnosed with dementia, their families and carers and professionals to enable people to maximise their independence and live well with dementia. Tier 1 Essential Primary Care What needs to happen? Raise awareness of dementia symptoms Increase knowledge and understanding of dementia within primary care Improve access and approaches to early diagnosis and interventions Delivery of seamless pathway across both health and social care services through single point of access for people suspected or diagnosed with dementia Care planning, management and monitoring of treatment within primary care with the support of self management Responsive services to meet the changing needs of people at end of life care stages Effective and advanced personalised care planning and care co-ordination at end of life care stages What will it look like? All people with dementia and their families and carers will have easy access to a diagnosis and care and be recorded on the Practice dementia register. All GPs will understand the symptoms of dementia and carry out physical assessments (as set out by NICE guidance) for people suspected with dementia and refer cases to a single point, the memory assessment service in Tier 3. Primary care will accompany referrals to specialist care with information and signpost to support services within the third and voluntary to the patient and their families. Three monthly reviews will take place for every patient with dementia receiving antipsychotics solely for behavioural and psychological symptoms in dementia, which will be accompanied with a new or updated medications care plan. Timely and detailed communications and liaison from Tier 3 CMHT to Primary care to facilitate and support patient management within Primary Care. Tier 2 Enhanced Essential Primary Care What needs to happen? Identification of patients diagnosed with dementia with 2 or more Long Term Conditions Early identification of patients diagnosed with dementia at risk of hospital admission (acute/inpatient) in collaboration with Community Nursing/Tier 3 CPNs & Social Workers 7

8 Improve diagnosis rates of dementia through professional education and application of evidenced based research Identification of patients coded with dementia and with co-morbidities to have formal assessment in place, care plan and regular reviews to avoid emergency admissions (QP) What will it look like? The enhanced essential primary care will be set out through the levers of QP and Local Enhanced Services (LES) for QP has already set out practice requirements and audit process to evidence achievement relating to emergency admission avoidance. Tangible and measureable indicators are being set against outcomes in December 2012 which will then be to monitored and reviewed through the LES governance routes. Professional education to be developed to enable the improvement of diagnosis rates at Practice levels to respond to Locality population needs. Tier 3 Specialist Care in the Community What needs to happen? Functions, roles and responsibilities specified to provide consistent and high quality specialist care in the community for people with suspected/diagnosed dementia Improved access to early diagnosis and interventions through the implementation of a memory assessment service Proactive approaches developed to prevent and manage crisis responses within the community Specialist support and training to generic services and community support provision (in-reach and out-reach) Effective and advanced personalised care planning and care co-ordination at end of life care stages What will it look like? Tier 3 is a consultant-led specialist MDT service delivered in community settings. Referral to this tier is to provide temporary specialist input due to complexity of clinical and social needs presented within Tier 1 or 4. The functions provided by this Tier through the Older Adults Community Mental Health team will be memory assessment, complex case management, distressed reactions and a links to crisis responses. Following referral from GPs or notification from liaison psychiatry, MDT assessments will take place to produce a new or update an existing a care plan outlining treatment and interventions led by the Care Coordinator for the case. The assessment will take into account all needs including social and personal as well as medical and clinical needs. Post diagnosis the service should include information, advice and support, counselling and care planning for the future. The service should include assisting people with Advanced Care Planning at an early stage. This will enable individuals to maximise choice and control over their lives and extend autonomy for as long as possible. The care plan will be person-centred focused to enable the individual to return (upon discharge from Tier 3) to management of their dementia either within primary care (Tier 1) or self-management (Tier 0). Tier 4 General Hospital or Specialist Hospital based Inpatient Care What needs to happen? Improved access to liaison psychiatry services within general hospital wards to support clinical management and facilitate early and supported discharge 8

9 Appropriate referral to neurology and senior health medicine outpatient clinics with links to Tier 3 services for people suspected or diagnosed with dementia Ensure people are only admitted to inpatient OPMH wards following consideration of all options Ensure the minimum length of stay for patients admitted for assessment and treatment within OPMH wards Effective discharge planning for admitted patients to OPMH wards to avoid delays and reduce unnecessary lengths of stay What will it look like? High quality and appropriate care will be received within general hospital care settings and wards through the provision of specialist care provide by liaison psychiatry and links with other hospital departments and community specialist care involved in the diagnosis and treatment of people suspected or diagnosed with dementia. Staff in general hospitals will have training in, be sensitive and offer appropriate care to meet the needs of people with dementia in this setting. OPMH inpatient beds will be used effectively for assessment and treatment episodes, with links made with Tier 3 and general community services to enable effective discharge planning, reduce length of stay or delays due to community support requirements not being in place. 9

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11 3. Delivering the Five Tier Model of Care for Dementia NHS Wandsworth and agency partners are committed to delivering the five tier model of care reflected in the joint planning and working operating within the Older Adults Mental Health Clinical Reference Group. The aim of the dementia model of care is to achieve a step change from late diagnosis and crisis interventions for people diagnosed with dementia to early identification, support and management of dementia within primary and specialist services and through self management. To deliver the five tier model of care for dementia there will need to be investment and re-investment across the dementia pathway through the reconfiguration of existing services and de-commissioning of services which are do not provide value for money or deliver expected outcomes to people diagnosed with dementia and their families and carers. At a high level the specifications to deliver integrated model of care for dementia are being developed, with Tier 3 specialist community care - due to be completed in late December 2012, the general care services forming part of the community services redesign programme, Tier 4 has a separate sub-group delivering the national dementia strategy objectives for general hospital, which will feed into the acute specifications delivering care to Wandsworth. The action plan below outlines how and when each Tier will be developed from December 2012 to March

12 Tier Action Required Timescale Self Management Review of current self management provision to demonstrate outcomes achieved based on section 2.2 and value for money Guide to dementia services to be produced Gap analysis of self management provision to align with the increase in early detection and diagnosis rates Public awareness campaigns developed and implemented in response to refreshed dementia needs analysis MH Promotion strategy developed Initiatives from MH promotion strategy implemented Essential Primary Care Dementia awareness and education sessions delivered by Tier 3 and GP Lead for Dementia on dementia model of care, in particular, early identification and Memory Assessment service Guide to dementia services to be produced and distributed by GPs as per the dementia pathway Medication care plans and reviews to be undertaken managed by QoF initiative Single point of referral for memory problems - MAS referral proforma to be developed and used as standard audit to be undertaken Medication care plans and reviews to be undertaken managed by QoF initiative Tier 3 communication and processes to have set response times and monitored for efficiency Education and increase in advance planning for EOLc to be developed 12

13 Enhanced Essential Primary Care Evidence submission for QP Emergency Admissions Support strategy and initiatives developed in response to QP audit outcome Development of specific service requirements for dementia to be included in the Local Enhanced Services (LES) for Performance of LES monitored and support strategies implemented (where required) Public Health locality based needs population to be used to inform professional education plans at Practice level Specialist Care in the Community Develop service model for specialist care (OA CMHT) functions (includes CMHT, MAS, day services input and crisis resolution for functional needs & merger into 1 team) Develop and sign off specification for OA CMHT functions Evaluate pilot for Distressed Reactions service Specification & implement Distressed Reactions service Pilot initiative to address crisis resolution provision for organic needs Develop pathway for specialist support into generic community services (through Planning Care Together programme) Plans developed to provide specialist training, education and support to other Tiers and LTC models of care 13

14 General Hospital or Specialist Hospital based Inpatient Care Map current provision and service gaps for liaison psychiatry services within general hospital wards Out of hour pathway development linked to Integration programme and crisis management service development Develop Delayed Transfer of Care policy with WBC Monitor & review of referrals and activity relating to OPMH inpatient wards- links to SW London led initiaitve Monitor & review service developments for the General Hospital dementia plans in line with objective 13 of National Dementia Strategy Development of discharge planning strategy 14

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