PROJECT INITIATION DOCUMENT We re in it together People living well with Dementia in the East Midlands: Improving the Quality of Care in Acute Hospitals Version: 1.1 Date: February 2011 Authors: Jillian Guild East Midlands Strategic Health Authority Page 1 of 11
Project Initiation Document History Revision History Date of this revision: Revision Date Summary of Changes Version February 2011 Update following National Audit Office Report 1.1 Distribution Name Organisation QUPP Board Annette Lumb Professor Rowan Harwood Dr Steve Rutter Emma Spencer Clinical Leads Network Discovery Group people living with dementia Health and Social Care Regional Department of Health Nottingham Queens Medical Centre Kingsmill Hospital Mansfield Leicestershire Hospitals East Midlands East Midlands Page 2 of 11
1. Project Background National Context Dementia is one o f the most important issues we face as a society and as healthcare providers as more people are living longer. Numbers will double in England over the next 30 years and the cost of caring will treble from 17 billion in 2009 to 50 billion in 2030. In the East midlands, there were 52,836 people living with dementia in 2010 and prevalence of dementia will rise faster than the national average, expected rise to 82,155 by 2025. Such an unprecedented rise in numbers and associated costs means doing nothing is unaffordable Existing services for people with dementia are acknowledged to be underdeveloped across England and only a third of people with dementia receive a diagnosis (..% in East midlands) Up to 1/3 of people in hospital beds and 2/3 of people living in care homes have dementia. Anti psychotics are over prescribed to people with dementia and the Government expects prescriptions to be reduced by 2/3 by Nov 2011 People living with dementia are at greater risk of developing physical ill health and accidents (especially falls) as this is translated into a higher percentage of people with dementia in hospital populations than in the community populations Living Well with Dementia, the National Dementia Strategy (DH 2009) and the national review of anti psychotics (Banerjee2009) provide a framework for change. The strategy aims to support people to live well with dementia through better public awareness of dementia, improved early diagnosis and intervention and improved quality of care. Quality outcomes for people with dementia (DH 2010) and The Operating Framework 2011-12 (DH 2010, 4.19) describe the Coalition Governments continued commitment to the dementia strategy. Both reports specifically state that NHS organisations are expected to make progress to improve quality of care for people with dementia in acute hospitals as a priority. In addition, NICE Quality Standards for Dementia (July 2010) are part of The NHS Outcomes Framework 2011/12 and will inform commissioning and provider payment mechanisms. A number of reports have also been published on dementia care in acute hospitals (Counting the Cost 2009, Acute Awareness 2010, No health without mental health 20.. and Who cares wins 20..) and the Royal College of Psychiatrists has produced a case note audit, observational tool and organisational checklist for dementia in acute hospital care. Page 3 of 11
The key recommendations for acute hospitals from all policy documents and reports are summarised in table 1. Recommendations Data Collection and Review: Acute Hospitals 1. Coding of dementia 2. Length of Stay 3. Readmission rates for dementia 4. Regular review number of in-hospital falls 5. Complaints analysed by age 6. Review feedback from patients e.g. engage patient forums 7. Recording of incidents and risks 8. Audit access to CT and MRI for people suspected of having dementia 9. Audit maximum response time to obtain specialist assessment 10. Audit of environment Recommendations Acute Hospitals 1 Senior clinical lead for dementia 2 Access to liaison mental health service 3 Dementia pathways in place and all physical pathways have a mental health component 4 Resource Workforce Development plan for dementia 5 Routine nutritional and cognitive screening and help at meal times 6 Assessment of cognition and capacity 7 Personalised individual care plans 8 Carers assessments offered routinely 9 Plan to reduce prescribing of anti psychotics 10 Plan to improve discharge through dementia friendly discharge planning procedures and information sharing protocols 11 People admitted from their own home should only be discharged to a care home as an exception 12 Dementia friendly environments 13 Improve coding and data collection 14 Identify needs and plan palliative care Page 4 of 11
Key Facts and Figures: Dementia and Acute Hospitals Efficiency Reports indicate that improving quality in acute hospital care has potential to save money and such savings would benefit both acute trusts and commissioners. For example If a person with dementia left hospital 1 week earlier this would save at least 80 million nationally (Counting the Cost) 6 million per DGH could be saved If dementia was better managed (Quality outcomes for people with dementia) Implementation of the strategy is dependent on achieving 1.9 billion of efficiency savings by reducing reliance on care provided to people with dementia in care homes and acute hospitals (House of Commons Committee report 2010) therefore commissioners will be looking to contract with acute providers to deliver improved efficiency. Incidence in Acute hospitals People 65+ with dementia occupy 25-30% of total hospital beds 42% of individuals over 70 with unplanned admissions to an acute hospital have dementia rising to 48% over age 80 60% of people with dementia enter hospital from their own home and 33% of people with dementia enter hospital from a care home The TOP 5 reasons for admission where dementia is a secondary diagnosis are falls, fractured hip, UTI, chest infection, stroke People with dementia are more prone to develop physical illness and the presence of dementia complicates another illness Dementia is a major risk factor for falls (50% of hip fracture patients have dementia) and falls account for 40% of patient safety incidents in general hospitals 2/3 of people with dementia in hospital have delirium and delirium is associated with increased mortality, increased length of stay and poor prognosis. Preventative interventions can reduce incidence of delirium in acute hospitals by 30-40% Length of Stay People with dementia stay longer than others admitted for the same procedure and the longer the length of stay the worse the effect on physical health and symptoms of dementia and the more likely discharge to a care home Use of anti psychotic drugs increases with longer length of stay The presence of dementia and delirium increases with length of stay by up to 10 days Page 5 of 11
Specialist multidisciplinary care can reduce length of stay following hip fracture for those with mild and moderate dementia Experience and outcomes Over 1/3 of people with dementia admitted from their own home are discharged to a care home Dementia is a predictor of inappropriate or delayed discharge Counting the cost (200 ) found that 47% of carers said hospital had a significant negative effect on the person with dementia physical health which was not as a direct result of the medical condition,77% carers were dissatisfied with the overall quality of acute hospital care and 1/3 of these carers went on to make a complaint Poorer outcomes result from a person with dementia admitted to a general hospital for a medical procedure than a person without dementia being admitted for the same procedure The presence of mental illness including dementia may overshadow the recognition and treatment of physical health problems Key findings from the RCP National Audit of Dementia (Care in general hospitals) 95% of hospitals do not have mandatory training in dementia awareness Less than 1/2 of patients received a formal mental status test upon admission to hospital. Very few hospitals collect details about a person s background, routine and care needs ( personal profile ) 1/3 of patients referred to in-hospital psychiatry liaison services not seen within 96 hours. Fewer than one in ten hospital executive boards regularly review readmission data for patients with dementia and only one in five regularly review information on delayed patient transfers. Page 6 of 11
2. Objectives To support the lead clinical network on a regular basis To ensure that each acute hospital has a clinical leadership board in place To ensure that each acute hospital has a clinical lead in place To ensure that each acute hospital has an action plan in place to drive quality up Support each acute hospital to identify each of its main strategic priorities for action Support all the acute hospitals with the outcomes of the National Audit of Dementia by providing them with support for either one regional event or 5 individual sub-locality events Work with the Royal College of xxx to run the events Support each locality with action plans and care pathways 3. Project Scope Acute Hospital providers All hospitals in the East Midlands Care Pathways within the hospitals 4. Constraints Engaging with key stakeholder in a timely way Regional Dementia Leads finish 31st March 2011 Clinical leads finish June 2011 Local Dementia leads finish between April 2011 and July 2011 Conflicting local priorities 5. Assumptions Key stakeholders will engage Collective response from Acute Trusts Existing work will be built upon Build on existing work and enthusiasm Relationships are good with shared vision and understanding Good practice will be shared across partners New priorities to be agreed and performance managed Royal College will continue to work with us and provide support Key partners understand the pathway Completion o f new specifications Page 7 of 11
6. Outline Business Benefits Enhanced quality Efficiency gains Robust business planning Trusts positioning themselves for future GP consortia commissioning arrangements Reduction in length of stays Prevention of hospital admissions 7. Project Approach / What we are going to do / How are we are doing it Regional leads to support with co ordination until 31 st March 2011 Clinical leads in place until June 2011 Action plans from all acute trusts submitted by Feb 2011 performance teams performance manage the action plans Regional leads work with Royal College to plan events/workshops Staff resource printed and disseminated to all acute trusts Work in partnership with EMPACT to ensure correct consistent approach to data collection and coding Collate and share good practice across the region Metrics grid for social care data from EMPHO Variation for NHS/Acute and QOF data from Quality Observatory 8. Project Budget Budget of up to 120k to support with the regional Dementia program is held with Derbyshire Mental Health trust under Chief Ex sponsor Mike Shewan Staff resource pack to be funded from EMDC budget Page 8 of 11
9 Project Plan and milestones Project stage or phase Milestones Anticipated completion / delivery date Leadership group First meeting Dec 22 nd 2010 Draft letter to Acute Hospital Chief Ex to Understand their priorities in relation to the Royal College Audit Letter agreed and signed by Professor Harwood And Kathy McLean Letter sent to All trusts January 5 th 2011 Letters sent and returns back 1 st February 2011 1 st February 2011 Chase Trusts if no response to first request Liaise with Royal College Project Team to organise event/workshops for all 5 sub-localities First prompt to letter Contact Chloe Hood NAO project Team 14 th February 2011 Jan 2011 Design resource pack for staff working in acute settings Leadership group Agreed contents February 2011 Data coding guidelines for acute hospitals Work in partnership with Clinical Leads Network and EMPACT to agree data collection Share at Regional Clinical Leads Meeting Agree data with Clinical Leads 16 th February 2011 February 2011 Work with the performance team to Ensure that they are fully up to date with the Program and the action plans from each acute trust Plan event/workshops with regional leads And Royal College Meet with Performance team Meet with clinical Leads to agree Way forward February 2011 February 2011 Page 9 of 11
10. Project Organisation Structure Position Name Title Project Sponsor Mike Shewan Chief Executive Derbyshire Foundation Trust Project Manager Jill Guild Strategic Relationship and Program Manager EM QUIPP Lead Annette Lumb EM Regional Department of Health Regional Clinical Lead Professor Rowan Harwood Consultant Geriatrician Queens Medical Hospital Nottingham Clinical Lead Dr Steve Rutter Consultant Geriatrician Kingsmill, Mansfield, Notts Clinical Lead Emma Spencer Service Development Leicester Hospitals Discovery Group Members Heather and Dave Roberts Patient and Carer 11. Project Communication Plan Both regional leads are working with the East Midlands and the Regional Joint Improvement Partnership to ensure that both web sites will be up to date with all communications in relation to the East Midlands Dementia Strategy Page 10 of 11
12. Risks Risk No regional capacity from 31 March 2011 Likelihood Impact Mitigation 1 (low) - 5 1 (low) -5 5 5 Localities Own projects Person Responsible Acute Hospitals do Not identify dementia As a priority 3 5 Performance manager Commissioners Will not performance Manage acute Trusts 3 5 Performance manage Acute trusts may not Appoint a clinical Lead and give enough of their resource to lead the plans 3 5 and Commissioners Performance manage Commissioners Ensuring that local Intermediate care/re ablement Plans that do include Dementia 3 5 Discussions with Lead commissioners to Ensure that service specs Include this element Acute trusts adopting the Coding guidance for Dementia 3 5 Discussions with acute Chief Ex Page 11 of 11