8 Pillars Model: Improving Co-ordinated Care for People with dementia and cares in the community

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1 8 Pillars Model: Improving Co-ordinated Care for People with dementia and cares in the community Michelle Miller/Portfolio Lead: Focus on Dementia 28 April 2017, ADI Conference, Annex Hall 1: 16:00-17:30

2 Dementia in Scotland 5.4 million population 93,000 People living with Dementia 16,000 People newly diagnosed each year (incidence data, 2017) Scottish Government priority since 2007 Third Dementia strategy due to be published Summer 2017

3 Focus on Dementia: National Improvement Portfolio Diagnosis and Post Diagnostic Support Integrated Care Co-ordination Advanced Care Primary Care, Community, Acute Hospitals, Specialist Dementia Units

4 Dementia Local Delivery Plan Standard To deliver expected rates of dementia diagnosis, all people newly diagnosed with dementia will have a minimum of a year s worth of post-diagnostic support coordinated by a link worker, including the building of a personcentred support plan. (Scottish Government Target, introduced 2013) Alzheimer Scotland 5 Pillars Model

5 8 Pillars Model Supporting people with moderate to severe dementia By tackling the full range of factors that influence the experience of dementia in a co-ordinated way, this work takes a therapeutic approach to enhancing the resilience of people with dementia and their families and carers. Alzheimer Scotland Model

6 Testing the 8 Pillars Model 5 Health and Social Care Partnership Areas

7 Data set summary (109 people with dementia) Not known/not required, 8% Under 65, 8% Over 85, 31% 65-75, 18% Had not received PDS, 36% Received PDS, 56% 76-85, 42% 56% of people had post diagnostic support 42% of people aged 76-85

8 Improvement approach: Breakthrough Series Collaborative X5 Test Sites X11 Learning Sessions Webinars Peer Support/Action learning sets Bespoke on-site support Building capacity and capability Data for improvement Carer and Staff focus groups & interviews Sharing learning and good practice

9 Evaluation an assessment on the overall effectiveness of the 8 Pillars model in enabling people with dementia to stay living well and as independently as possible at home for as long as possible; the importance of the role of the Dementia Practice Coordinator (DPC) in that process; and, an evaluation of the applicability and relevance of the proposed service model in the context of wider policy landscape in Scotland, for example in the areas of the integration of health and social care, the reduction in unplanned hospital care

10 Dementia Practice Coordinator identifies the individual needs of the person with dementia and their carer, supporting them on an on-going basis throughout their journey, coordinating access to each of the pillars and linking with the relevant practitioners and services to provide effective support and intervention across health and social care.

11 Dementia Practice Co-ordinators Crisis prevention and intervention Reducing Falls Avoiding hospital admission Supporting earlier discharge from hospital

12 Summary of Evaluation Findings People with dementia and cares valued single point of contact. This role is key (Dementia Practice Co-ordinator) to crisis prevention and intervention. Specialist Dementia Team Approach providing Dementia Practice Co-ordination enabled more flexible approach to providing support for people at different stages Communication and data sharing understanding and appreciating different roles, role shadowing Leadership and national improvement and educational support transformational change 8 Pillars is a useful framework for supporting people with dementia at moderate to severe stage of their dementia. DPC comment: Examines all aspects of a person s life, not just the aspect most directly concerned with their own professional practice.

13 Supporting Implementation Role recognition: Autonomy to act Responsiveness: Right Support at Right Time Person with dementia and carer Personal Outcomes Readiness for Change & Re-design to meet changing demands Right level of knowledge and Skills

14 Unintended Consequences Dementia Friendly Community Developments Improved diagnosis rates Catalyst for transformational change

15 Next Steps Publication of evaluation findings Spreading learning and supporting transformation Links with Act on Dementia

16 Thank @MichellexMillr Web: ihub.scot

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18 The Improvement Hub (ihub) is a part of Healthcare Improvement Scotland

19 Personalised Outcome Plan 75% 30% People with Dementia have a Personalised Plan Carers have Personalised Plan

20 Personalised Support Analysis 67% 79% 97% General Health Care / Treatment Analysis 60% 70% 80% Environment Analysis 24% 53% 77% Mental Health Care / Treatment Analysis 55% 66% 76% Support for Carers 55% 75% 70% Therapeutic Interventions Analysis 45% 66% 62% Community Connections Analysis 33% 57% 65% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jan-Mar 2015 Oct 2015 Mar 2016