1 Action Plan Dementia diagnosis and post diagnostic support Dated: 10 th May 2018 Version: V8 Aim: To support practices to diagnose and record dementia and to improve system wide post-diagnostic support Objective: To improve the dementia diagnosis rate from 64% (March 2018) to 67% by the end of March 2019 Executive Accountability: Rebecca Hulme Clinical Lead: Dr Ardyn Ross Monitoring: Kim Harvey Key for RAGBW rating of Actions: (W)hite = Not yet started (G)reen = Completed (A)mber = In progress (R)ed = Due but not complete (B)lue = Ongoing monitoring to be assured of continued achievement ID 1. Objective: To improved data quality and understand the information to support the increase in the dementia diagnosis rate ID Action Required Responsibility Timescale RAG Updates 1.1 Validate the number of people required per GP practice to achieve the dementia diagnosis % with NHSE assurance team R Hulme 31 Aug 2017 G
2 1.2 Validate the prevalence data per GP R Hulme 31 Aug 2017 G practice with the NHSE assurance team 1.3 Use public health research to confirm the population and demographics per GP practice A Bagade 30 Sept 2017 G The CCG holds this information. And the practice populations have been calculated using the methodology as applied by NHS Digital 1.4 Review EMIS data BI Team 31 Jan 2018 G Cross checking of codes has 1.5 To understand the attrition rates in the following areas: - death and diagnosed with dementia - death and undiagnosed with dementia - dementia diagnosis recorded on death certificate 1.6 To write to Professor Alistair Burns about local prevalence Public Health/ K Harvey 31 July 2018 W generated a few new cases Dr A Ross 28 Feb 2018 G Response from Alistair Burns received by Dr Ross on 17 th April 2018. He confirmed that the DDR is an estimate and that the true value falls within a range as indicated by NHS Digital. NHS England have explored whether or not the apportionment of national prevalence between CCG s could be improved using additional risk factors. This it would appear did make a difference to how national prevalence was shared
3 1.7 Contact with Castlepoint and Rochford CCG to be initiated to support review of action plan and trajectory 1.8 Feedback on data queries highlighted at meeting on 13 th February 2018 to be given to the CCG G Munn (NHS England) G Munn (NHS England) between CCG s. However, this was not better or worse than the existing method. There was an acknowledgement that the prevalence estimates are not perfect and NHS England are exploring whether it is the time to refresh the estimates used nationally. The important of the DDR was noted but achievement of it not as important as progressing and ensuring continuous work to improve DDR s. Dementia diagnosis is the gateway to post diagnostic support. 31 Mar 2018 A This is still to be arranged. But CPR have agreed to meet with GYW. 31 Mar 2018 A Response in relation to action plan received 30 th April 2018 and feedback on the data queries is still outstanding. 2. Objective: To support GP practices in achieving the dementia diagnosis rate by the end of March 2019 2.1 To risk stratify the practices where there is opportunity for significant improvement in their dementia diagnosis rates and to enable more targeted support S Morris 30 Sept 2017 G The CCG has a list of GP practices who would benefit from targeted support in increasing their diagnosis rates.
4 2.2 To undertake targeted visits with the identified practices 2.3 Introduce the Dementia Quality Toolkit (DQT) into all GP Practices 2.4 Review how many GP practices are using the DQT following its introduction 2.5 Lead clinician to deliver training to localities to promote best practice with regards to diagnosing dementia and also the benefits of diagnosis 2.6 To confirm the % of 65+ patients with a dementia diagnosis who have had a care plan review under QOF Dr A Ross 31 Oct 2017 G Dr Ross has visited a number of under-performing practices and cross referenced information this has led to a few new cases being added to registers C Angell/A 30 June 2018 W Baldry C Angell/A 30 Sept 2018 W Baldry Dr A Ross 31 Mar 2019 A Dr A Ross 30 June 2018 W Awaiting 2017/18 QOF data which is due in June 2018. 3. Objective: To involve other professionals and stakeholders in increasing the dementia diagnosis rates by the end of March 2019 and to raise awareness of the importance of individuals having a dementia diagnosis 3.1 Promote methodical review of patients with memory problems or those at high risk. - Making every contact county - Review of individual with a mild cognitive impairment diagnosis (yearly but agreed this is not a new referral to memory treatment services) - Eclipse search to be validated by GP practices K Harvey/Dr A Ross 30 Sept 2018 A Yearly reviews of patients with a Mild Cognitive Impairment already takes place. To confirm which GP practices have registers to record these reviews.
5 3.2 To include dementia diagnosis in the Care Home LES 3.3 Ensure that providers in their discharge letters/summaries detail an ICD 10 code to inform dementia diagnosis 3.4 To determine how many occasions the dementia code is recorded within the acute general hospital setting Dr A Ross/A Baldry 31 Mar 2018 G The Care Home LES commenced on 1 st April 2018 K Harvey 31 July 2018 A BI Team 30 June 2018 W 4. Objective: Review and redesign memory treatment service pathway for Norfolk and Waveney 4.1 Review the current memory treatment service pathway provided by NSFT by carrying out a clinical review. 4.2 Outcome of clinical review and recommendations to inform development of proposed primary care dementia service 4.3 Norfolk and Waveney STP Task and finish group will design new model involving NSFT & Primary Care N & W CCG s 31 July 2018 A Next meeting of the Norfolk and Waveney STP Task and Finish group is taking place on 29 th May 2018 N & W CCG s 30 Sept 2018 W K Harvey 31 Dec 2018 W 4.4 A shared care protocol will be in place Dr A Ross 31 Mar 2019 W 5. Objective: Review and develop a post-diagnostic support service for Norfolk and Waveney 5.1 Review the current post diagnostic support available in the locality to establish baseline and gaps K Harvey 30 April 2018 G All Norfolk and Waveney CCG s have a baseline of what post diagnostic support is available in their localities.
6 5.2 Norfolk and Waveney STP Task and finish group will develop the post diagnostic support 5.3 Contact the Alzheimer s Society to understand the post diagnostic support course for people with dementia and their carers that they can deliver 5.4 Liaise with Dementia UK Consultant Admiral Nurse to understand the post diagnostic support they can provide 5.5 To implement a post diagnostic support pathway for Norfolk and Waveney 6. Objective: N & W CCG s 30 Sept 2018 W K Harvey 31 Mar 2018 G Local co-ordinator for Alzheimer s Society contacted on 27 th September 2017 for information about a post diagnostic support course. Information on this has been supplied K Harvey 31 Mar 2018 A N & W CCG s 31 Mar 2019 W Governance Oversight by the GYW CCG MH & LD Delivery board Detailed report on activity and performance to the Quality Finance & Performance Committee Update report to the Norfolk and Waveney Mental Health STP Forum Report to public part of the Governing Body Monthly Monthly Monthly Bi-monthly Risk Mitigating Actions Non-engagement by GP practices Increased communication to all practices Introduction of the dementia diagnosis rate as part of the GP dashboard Introduction of the Dementia Quality Toolkit (DQT) to all practices
7 Identification of practices where lessons can be learnt and shared from good practice Appendix 1 Dementia Diagnosis Performance Summary