Dementia in Disability Sector Meeting Regulatory Requirements April Florence Farrelly (IM) Regulation Directorate

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2 Dementia in Disability Sector Meeting Regulatory Requirements April Florence Farrelly (IM) Regulation Directorate

3 This Presentation Brief overview of the regulatory context General overview of what a good service looks like Summary service looks l Regulation Directorate

4 The Regulatory Framework - Health Act 2007 The Law Primary Legislation Regulations Standards Criteria & Features Regulations are the law - Standards set out a vision for quality Standards, legislation and regulations are intended to work together to assure quality in services Regulation Directorate

5 STATISTICS HIQA Regulate nearly 1200 centres registered yet to complete the process National Intellectual Disability Database Committee 2016 Annual Report (Published June 2017) 7,612 people in receipt of full- time residential services Of the 7,612 full-time residents, 6,288(82.6%) have a moderate, severe or profound level of intellectual disability, 4,279 (56.2%) were living in community group homes and 2,135 (28.0%) were living in residential centres 6,541 (85.9%) were aged 35 years or over Regulation Directorate

6 What does a good service look like? What residents experience on a day to day basis Is determined by the person in charge ensuring that best practice occurs at all times And by the registered provider having robust assurance arrangements in place Regulation Directorate

7 RESIDENT EXPERIENCE - WHAT SHOULD THIS LOOK LIKE/FEEL LIKE FOR A PERSON WITH DEMENTIA Services are appropriate, person centred, evidencebased & enabling of each person Initial and continuous assessment/review Each resident is safeguarded in a way that is as least restrictive as possible Each person's rights are protected Regulation Directorate

8 RESIDENT EXPERIENCE - WHAT SHOULD THIS LOOK LIKE/FEEL LIKE FOR A PERSON WITH DEMENTIA (CONT.) Healthcare needs are met Opportunities to engage in appropriate social or community activities Controls to reduce risks are in place Appropriate response to behaviour that challenges Living with peers Suitable environment Regulation Directorate

9 ENSURING - WHAT SHOULD THIS LOOK LIKE FOR A SERVICE DELIVERING CARE TO A PERSON WITH DEMENTIA Genuine focus on personal choice and person-directed services. Are people being supported to have meaningful life opportunities Building services around the person Best practice Assessments and care/service planning are conducted in partnership with each person using services Regulation Directorate

10 ENSURING - WHAT SHOULD THIS LOOK LIKE FOR A SERVICE DELIVERING CARE TO A PERSON WITH DEMENTIA (CONT.) Robust risk management and oversight Complete /up-to-date care plans Staff had suitable training MDT input/medication management Implementation of safeguarding policy Management of resources/planning for changing needs Regulation Directorate

11 ASSURED - WHAT SHOULD THIS LOOK LIKE FOR A SERVICE DELIVERING CARE TO A PERSON WITH DEMENTIA Effective Governance and Management structure Actions arising from previous inspections been completed Demonstrating compliance against regulations and standards Own internal audit Regulation Directorate

12 SUMMARY Genuine focus on personal choice and person-directed services Building services around the person Are people being supported to have meaningful life opportunities Residents are safe, enjoy a good quality of life Continuous process of review Staff training Plan for changing needs Suitable environment Effective governance structure Regulation Directorate

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15 Innovations in Care 6 th Annual Conference, Northridge House Mary Mannix CNM Dementia Care

16 Cork IDeAS Project : Integrated Dementia Care Across Settings Genio, HSE & MUH Mercy University Hospital & Community working together Mary Mannix

17 3 year innovative project: Real life practice-based dementia care research Robson 2011 Aims The provision of integrated dementia care across services in Cork MUH will become a truly dementia friendly hospital Development of an integrated care pathway with links to other relevant pathways for components of the care journey which will be reflective of the National Dementia Strategy Provision of a template for other services/hospitals to adapt and implement.

18 Consortium 45 members Project lead Dementia Nurse Specialist Community Dementia Care Co-ordinator Occupational Therapist part-time Nursing Research Officer Independent evaluation by TCD In-home respite funding Education Fund

19 Improve hospital experience; Improve recognition of dementia/delirium by staff; Diagnosis highlighted on referral, Increased awareness by staff through educational package, Policy and tool for brief cognitive screening of vulnerable people on admission Improved care in hospital; Staff training Dementia Champions (2 per ward) Policy development for Dementia care Comprehensive assessment using validated tools Improved built environment DNS providing clinical care and leadership Facilitation of continuity of care by family or carers Organisation of Volunteers ED avoidance/limitation; ED notified if PwD needs urgent admission by G.P. ED processes/environment change Facilitation of discharge Development of outreach/community in-reach team CDC providing clinical care and leadership Target outreach facilities e.g. intravenous antibiotic service/memory clinic Discharge planning with involvement of person and carers, early notice of discharge Development of enhanced support The introduction of a formal passport system for those in residential care beginning in nursing homes receiving enhanced medical care from MUH

20 Changing culture/ Raising awareness Staff education/training/awareness (target approx. 700) 564 x General staff awareness sessions (45 mins) 10 x Dementia champions 47 x four hour acute care training + in-service training for nursing staff DSIDC Videos for Loan + Resource Packs for departments One- off events; August 2015 ED dementia education focus Nov 2015+Sept 2016 Dementia Awareness Week Induction Training: UCC pre intern training 2016, MUH induction training/medical &Nursing

21 Developing the Integrated Care Pathway An ICP is a complex, repetitive process guided by: In depth literature reviews Process mapping Framework development key stakeholder meetings Followed by pathway implementation and evaluation.

22 Process Mapping 1 ODCACS (Cork Dementia study) data: 33 admissions with dementia in the two weeks 900 per year; 56% mild; 22% severe 18% from NH (77% of all NH admissions all hospitals had dementia) 25%, (high) admitted from home went to LTC

23 Feb 10 th 2016: Age and Aging 606 Patients over the age of seventy admitted to six hospitals in Cork County 29% in public hospitals had dementia 57% had a delirium superimposed Diagnosis known on admission 36%

24 Process Mapping 2: Admission to MUH/ ED 114 Hospital Admissions for 1 week among patients 70 years (July 2014) 70% admitted through ED... Only 43% of ED attendees had GP letter Mean duration in ED/AMAU from presentation to discharge: 9.5 hours 185 older Mercy Hospital ED attendees: July % had delirium 24% had dementia Most delirium occurred in people with dementia (75%) Older people brought by ambulance had significantly more dementia (46% v 18%, p<.001) and delirium (30% v 14%, p=0.012) Of those aged 80 and older, 32% had dementia and 28% had delirium.

25 Process mapping 3: Case note review 60 Patients with HIPE code for dementia completed January (Jan-Jun 2014) 57 presented to ED, 2 went to AMAU, 3 were elective 34 had G.P. letters 28 presented from home, 29 from nursing homes, 2 St. Michaels, 1 CUH LOS 9.73 home to home, home to NH

26 Process Mapping 4 (ED Experience) Interviews with 6 older patients, and 6 relatives of patients with dementia. Findings High levels of satisfaction with care provision and treatment; relatives felt that procedures were carried out in a timely, efficient manner. Relatives often reluctant to leave patients alone in the ED, due to their confusion and a fear for their general safety. They were critical of the length of time that patients spend in the emergency department. Patients did not have similar concerns and overall, they did not complain about anything. Improvement needed: reduce the time patients with dementia spend in ED and assure family members of patient safety.

27 Process Cont d Literature review and synthesis of evidence based best practice to inform each stage of the pathway development and guide best practice Review guidelines to inform pathway development (NICE/SIGN/AGREE) Development of draft ICP Peer Review Framework

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29 Draft Overview Framework for Integrated Care Pathway for Dementia Community-Emergency-Acute-Community Care Raise Dementia Awareness in Community & Acute Care Staff Education/Trai ning This is Me Provide Carer Support -Memory Problems -Moderate dementia -Severe dementia Presenting From: Home Nursing Home Day Centre General Practitioner Suspected Cognitive Impairment Existing Dementia Diagnosis Acute Care N o Yes Treat at Home N Adm Alternatives to Acute Hospital o Care it Enter? Dementia Day Care/Treatment Pathway Enter Dementia Community Care Pathway Yes Emergency Department Acute Medical Assessment Unit Standard Cognitive Screening Enter Dementia Emergency Department Pathway Dementia Care Bundle -Memory Problems -Moderate dementia -Severe dementia Transferring from Other Hospital Out Patient Department Internal y Enter Dementia Assessment Pathway Discharge with Suspected Cognitive Impairment Discharge Enter Discharge Pathway Co morbidities Entry to Other Care Pathways / Acute Care/ Ward Admission Enter Dementia Acute Care Pathway for Early/Moderate/Severe Dementia Dementia Care Bundle Guidelines for Referrals Within Acute Care Home Enter Dementia Community Care Pathway Rehabilitation Enter Dementia Rehabilitation Pathway Convalescence Enter Dementia Convalescence Pathway Nursing Home Enter Dementia Long Term Care Pathway Palliative/End of Life Enter Dementia End of Life Pathway 06/09/2015 Dawn O Sullivan & Mary Mannix

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32 Support for communication and personalised care Mary Mannix

33 The Dementia Friendly Environment Before After St. Marys Unit

34 Wayfinding Cues St. Marys Unit

35 St. Marys Unit Emergency Department

36 Involving External Agencies The Examiner School of Architecture CIT woodwork ACME Blinds Discounts from suppliers Soundstore Murphy Electrical Fireplace Clocks Gardening Centres Harbour Flooring

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38 Transitional care unit, St. Francis unit

39 Volunteers SAGE Volunteers Pilot Site Co-ordinated by SAGE Evolved during the project: Regular - as needed Supported transitions to LTC Literacy support Advocacy Hospital Volunteers Co-ordinated by an expert volunteer Evolved during project: 18 volunteers Identified by Tee-Shirts +ID Badges Transitioning to/from diagnostic appointments Buddy walking ED: requiring accompaniment

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41 Integrated working approach between hospital and community Hospital avoidance and supported discharge In reach-out reach: DNS +CDC The Community Dementia Care coordinator

42 Changing Culture Staff education/training/awareness (target: Primary Care Team) Dementia Awareness Sessions; PHN X 271 Dementia Champions Dementia Education and Resource booklet Links with PREPARED Project + roll out to PCT s New GP Dementia Module Dementia Services and Resource Guide

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44 Integrated Dementia Care Pathways Change Management enabled by: Special Qualities in MUH Dedicated Staff for project Dementia is now a national strategy Multifaceted approach, leading with awareness Regular updates and reiteration Extensive involvement of many/fundraising Mary Mannix

45 Acute Consortium Members Dr. Suzanne Timmons, Geriatrician, Project Lead Mary Mannix, Dementia Nurse Specialist Sandra Daly, CEO Dr. Elaine Dunne, Mental Health Services Older Adults Dr. Gemma Browne, consultant Lead for Acute Medical Assessment Unit Josephine Griffin, Patient Liaison officer Margaret McKiernan, Director of Nursing Prof. David Kerins, Clinical Director Dr. Kieran O Connor (MUH), Dr. Catherine O Sullivan (MUH), Dr. Paul Gallagher (CUH) Dr. Ciara McGlade (MGH) Consultant Geriatrician Sile O Grady, Advanced Nurse Practitioner, Dr. Adrien Murphy, Consultant, Emergency Department Eileen Looney, Discharge Co-ordinator Anne O Hea, Anne Quirke, Occupational Therapists Ruth McCullagh, Physiotherapist Micheal Sheridan, Mercy University Foundation Sharon Maher, CNM St Marys Ward Coleman Rutherford, Head of Social work Emer O Regan, Dietician Grace O Sullivan, Coordinator, Hospice Friendly Hospitals Programme Doreen Lynch, Elizabeth Myers, Mercy Education Centre

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48 Video Podcast Mary Mannix

49 Communication Passport Mary Mannix

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