Section Dementia Strategy Contents Page 1. Introduction 2 2. Context of Northern and Eastern Devon 2 3. Our Values and Principles 3 4. Key Result Areas 5 5. Needs Analysis 6 6. Model of Service Delivery 10 7. Information Sharing 17 8. Standards 8.1 Standards in the community 17 8.2 Standards in the Acute and Community Hospital setting 18 9. Delivery and Improvement Plan 22 1
1) Introduction Northern Devon Healthcare NHS Trust (NDHT) provides acute and community services to the residents of Northern Devon and community services in the Eastern and Mid Devon area. The Trust is an integrated Trust delivering health and social care across acute, community hospital and home based services. This strategy outlines how as a Trust we will provide high quality care for people with dementia whilst they are accessing services provided by Northern Devon Healthcare NHS Trust. It sets out expectations of the service we will deliver and where we will work with specialist (dementia) providers of care to ensure we achieve agreed standards. Whilst this document outlines responsibilities and targets around the needs of patients with dementia, it should also be considered in conjunction with other Trust strategies including Falls Prevention and Management, Learning and development, Nutrition, Estate Strategy and the Safeguarding work plan. The strategy has been developed using the following documents to underpin the principles and key objectives: Living Well with Dementia A National Dementia Strategy February 2009 Joint Commissioning Strategy for people with dementia in Devon July 2009 The Nice Quality Standards for Dementia July 2010 South West Dementia Partnership Improving Care for people with dementia while in hospital September 2010 The South West Strategic Health Authority 2010 performance framework for delivery of the national dementia strategy - September 2010 Quality outcomes for people with dementia: building on the work of the National Dementia Strategy September 2010 South West Hospital Standards in Dementia Care; Full Report February 2011 In addition we have also included user input from complaints and PALS-collected commentaries. The Strategy will also move forward through the Trust Involving people Steering Group to ensure consistency with local views and values. 2) Context of Northern and Eastern Devon The Trust provides a wide range of local, community, general and specialist services to the residents of North Devon and Torridge District Council areas, a catchment population of 157,000. It provides a range of 2
community based services in Exeter, eastern and mid Devon to a population of around 325,000. The total population served of 484,000 represents just over half of the total Devon population. This figure is significantly augmented in the summer months by the influx of tourists, meaning the Trust has developed services with in-built flexibility according to demand. The demographics of northern and eastern Devon are broadly similar, with 21% aged 65 or older. There is an expected 40% increase in the 60-80 age group by 2021. Average life expectancies are higher than the national average, however, there are significant differences in life expectancy between the most and least deprived wards of each population, and each area has pockets of significant rural deprivation. Northern Devon includes the key urban areas of Barnstaple and Bideford. The balance is drawn from the highly rural population in a network of small hamlets and villages across the region, Eastern Devon includes the major urban area of Exeter, along with other urban areas of Exmouth, Crediton, Tiverton, Cullompton, Honiton and Sidmouth. The remaining population lives in rural areas across a significantly large geographical patch. Whilst many of the general public incorrectly believe dementia is a natural consequence of ageing there is a correlation with prevalence and age. Public perceptions mean that there is believed to be an unmet need and previously unknown dementia-sufferers accessing services late in their condition. 3) Our Values and Principles The vision of the Trust, adopted by the Board in 2008, is: To provide high quality health and social care services that reach out into our communities by promoting and investing in best clinical and employment practice. Underpinning this vision is the Trust s over-arching mission statement of: Keeping services local The four cornerstones of our strategy are: Excellent planned and emergency care Provided through our network of minor injury units in community hospitals and the emergency hub at North Devon District Hospital for the assessment and treatment of all patients who require urgent or emergency care. 3
Our focus will be on delivering top quartile performance in day surgery activity, length of stay and enhanced recovery for elective surgery. Services reaching out into the community We will provide more services in community setting, to overcome the barriers posed by rurality in this part of Devon. The Trust will offer flexible, accessible, patient-focused care closer to where people live and work. Having a network of community hospitals, resource centres and acute services under one management team makes true rural health and social care achievable Clinical partnerships and networking Many services will be provided through clinical partnerships and networks with other organisations, to ensure that care is safe and of high quality, and uses best clinical practice. Embedding public health and education in services We will play a key role in helping people live healthy lives and in promoting independent living. Services will have a strong focus on public health and reducing inequalities. In response to Lord Darzi s Next Stage Review High Quality Care for all, we have subsequently incorporated the fifth cornerstone: Quality should be the organising principle of the NHS. It defines quality in the NHS using three measures: patient safety, patient experience and effectiveness of care. Over the last two years the Trust has exerted concentrated effort on all aspects of quality. This makes it an important part of the Transforming Community Services strategy of the Trust. Our values Strategies can only be delivered if the values of the organisation are aligned with the vision, and if staff subscribe to those values. Following an extensive consultation as part of the development of our strategy, the values that underpin our culture and the strategy are as shown in the figure below. 4
4) Key Result Areas There are 17 key objectives within the National Dementia Strategy (2009) attached as Appendix a, many of which relate in varying degrees to services provided by NDHT. Additionally, the recently published South West Hospital Standards in Dementia Care (Feb 2011) sets out 8 standards for care against Objective 8 of the National Dementia Strategy (2009) and we have used this to inform our strategy for the care of patients whilst in hospital. For 2010/11 the Department of Health identified four priority areas which support local delivery of the strategy. The four priorities are: Good quality early diagnosis and intervention for all Improved quality of care in general hospitals Living well with dementia in care homes Reduced use of anti-psychotic medication As a Trust we have ensured this strategy for treating and caring for people with dementia addresses these four priorities by outlining how we will meet the 17 key objectives and the 8 standards for care of people with dementia whilst in hospital. 5
5) Needs Analysis ( the following statistics are taken from Joint commissioning strategy for people with dementia) The following maps and tables are included to graphically illustrate the increasing expected prevalence of dementia in Devon. The table below shows how significantly the prevalence of dementia increases in the 85+ age group. The figures are sourced from the Dementia UK Report which is based on prevalence by age banding as follows: Age Male% Female% 65-69 1.5 1.0 70 74 3.1 2.4 75 79 5.1 6.5 80 84 10.2 13.3 85+ 21.1 26.1 Analysis of the Joint Strategic Needs Assessment information with regard to older people s mental health and dementia in particular shows: The expected rise by 2021 in the number of people aged 65 and over in Devon is 39%. The number of people with Dementia based on national prevalence statistics is expected to increase from approximately 12,000 at present to 17,000 by 2021. The prevalence of dementia in the 85+ age group is a key factor for Devon and its impact is clearly visible in the maps below. This growth in demand will represent a significant challenge to existing and traditional services. It will be essential to recognise this shift in the age profile to enable effective planning and commissioning in anticipation of increasing demands for good quality, flexible services to meet the needs of people with dementia and their carers. The challenge is further compounded by the rural nature of Devon. Mosaic profiles indicate 24% of households in the County are in the rural isolation classification clearly having an impact on the way older people might be able to access services, and also in the way services will need to be organised to meet needs. 6
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What this means for Devon s towns in percentage terms between 2006 and 2021 s shown below. It is important to look at volumes alongside the maps above. 8
The following table shows the current numbers of patients registered as having dementia within the local population by PBC Consortium, against the expected prevalence. This will enable local targets to be identified in order to narrow the gap by 25% between the recorded incidence and expected prevalence by 2013. 9
6) Model of Service Delivery When people with dementia access NDHT services (community based or within the acute setting) it is essential that we understand their needs, wishes and capacity regardless of whether they have a diagnosis of dementia or are simply displaying a range of symptoms. It is estimated that up to two-thirds of people with dementia who are admitted to an acute bed are not formally diagnosed with dementia. The key component elements of our services will be focused around individual patient need, being responsive and flexible and will incorporate appropriate carer involvement as exemplified in the diagram: Information for Patients and carers Individualised Assessment Management of physical health needs High quality end of life care Patient Medication Review and Management Signposting to support Liaison with/referral to mental health services Home based continuing care Support for Carers Underpinning the care we provide will be the principles of ensuring people with dementia are treated with dignity and respect by a workforce that is appropriately trained. 10
Service Model In order to manage care appropriately we have identified 4 distinct patient groups with needs related to dementia who may come into contact with services due to their physical health and social needs. By identifying these groups we have been able to better articulate the nature of the service we should deliver, the need for advice and support and the need for specialist intervention. It is, however recognised that specialist mental health services do not necessarily operate 24 hours a day and so where input is required it would be on an appropriate and availability basis. The four groups can be identified as follows: Patients with pre-existing dementia (known) who come into contact with services in an emergency with acute behavioural disturbance or acute medical need that may exacerbate their presentation Patients with no known dementia but with persistent confusion/acute behavioural disturbance who come into contact with services in an emergency/crisis Patients with known co-morbidity of dementia which is stable who come into contact with services in a planned elective way or as an emergency Ambulant, disruptive patients with known dementia requiring stabilisation and/or medication review For each of these groups there are roles for the healthcare professionals who will be working with them regardless of whether their contact with services is within the community or acute hospital setting. It is also important to note that there are specialist services e.g. Bladder and Bowel, podiatry, cardiac rehab which may need to be engaged in the management of a patient s need and should be part of a co-ordinated approach to care and treatment. For each of these groups we have identified the services we will deliver and standards set for their care in all parts of the NDHT services. We will develop clear protocols and policies for the management of patients presenting to services to ensure clarity in the management of the patient pathway. 11
Patients with pre-existing dementia (known) who come into contact with services in an emergency with acute behavioural disturbance or acute medical need that may exacerbate their presentation Where Our role and responsibilities Devon Partnership Trust s roles and responsibilities In the community Timely assessment of need by member Sharing of previous information/ care plans of Complex Care Team (CCT) Psychiatric assessment as Provision of rapid required response Active involvement of Co-ordination of care and treatment plan Community Psychiatric Nurse (CPN) in care Specialist advice plans (as appropriate) (geriatrician) Provision of Liaison with previous CPN appropriate inpatient mental health bed if Appropriate/timely intervention by specialist community services required In a community hospital Assessment Detailed care plan identifying how dementia needs will be managed Assessment of need for referral to acute or specialist MH service Specialist advice (geriatrician) Staff trained in the management of behavioural problems Sharing of previous information/ care plans Psychiatric assessment as required Active support and liaison into the community hospital Provision of appropriate inpatient mental health bed if required In the acute setting Timely ED/acute assessment Detailed care plan identifying how dementia needs will be managed Early flagging to liaison service and Sharing previous management plans when requested (within 24 hours) Active involvement by liaison team in the development and review of management 12
Care Co-ordinator Review and management of physical health needs Regular assessment and review of management plan Medication review Linking with liaison service for support during inpatient stay Assessment of ongoing need post discharge and discharge planning Staff trained in the management of behavioural problems plans Proactive involvement in discharge planning Liaison service support and signposting Patients with no known dementia but with persistent confusion/acute behavioural disturbance who come into contact with services in an emergency/crisis Where Our role and responsibilities Devon Partnership Trust s roles and responsibilities In the community Timely assessment of need by member of CCT Psychiatric assessment as Provision of rapid required response Active involvement of Co-ordination of care and treatment plan CPN in development of care plans (as Specialist advice appropriate) (geriatrician) Provision of Appropriate/timely intervention by specialist community services appropriate inpatient mental health bed if required In a community hospital Assessment Detailed care plan identifying how dementia needs will be managed Detailed plan with triggers for escalation Assessment of need for referral to acute or Psychiatric assessment as required Active support and liaison into the community hospital Provision of appropriate inpatient 13
specialist MH service Specialist advice (geriatrician) Assessment of ongoing need post discharge and discharge planning Staff trained in the management of behavioural problems mental health bed if required In the acute setting Timely ED/acute assessment Review and management of physical health needs Establishing a diagnosis of the type of dementia with appropriate information given to patient, relatives and GP regarding this Linking with liaison service for support during inpatient stay Identification of risk factors Detailed plan with triggers for escalation Regular assessment and review of management plan Review of medication Staff trained in the management of behavioural problems Assessment of ongoing need post discharge and discharge planning Liaison support with development of management plan Advice and guidance on de-escalation options Liaison team support for discharge planning Ongoing care Patients with known co-morbidity of dementia which is stable who come into contact with services in a planned elective way or as an emergency Where Our role and responsibilities Devon Partnership Trust s roles and responsibilities In the community Development of individual care plan based on assessed need Ongoing care after discharge (as appropriate) 14
Liaison with previous CPN Appropriate/timely intervention by specialist community services In a community hospital Individualised assessment of need Management plans which recognise the diagnosis and include plans for escalation in the event of deterioration Appropriate information for patients and carers about treatment Assessment of ongoing need post discharge and discharge planning Specialist advice (geriatrician) Liaison support with development of management plan Advice and guidance on de-escalation options Liaison team support for discharge planning Ongoing care after discharge (as appropriate) In the acute setting Appropriate information for patients and carers about treatment Appropriate management of appointments in outpatients, pre-op, diagnostics Individualised assessment of need Regular assessment and review of management plan Management plans which recognise the diagnosis including escalation plansin the event of deterioration Allocation of bed for inpatient stay based on assessed need Assessment of ongoing need post discharge and discharge planning Support with development of management plan to prevent deterioration Timely support with development of management plan in the event of sudden deterioration Liaison input to review medication Ongoing community support following discharge (as appropriate) 15
Ambulant, disruptive patients with known dementia requiring stabilisation and/or medication review Where Our role and responsibilities Devon Partnership Trust s roles and responsibilities In the community Timely assessment of need Timely input from specialist mental Development of individual care plan based on assessed need health services Liaison with previous CPN Referral to secondary/ acute treatment Appropriate/timely intervention by specialist community services In a community hospital Assessment Detailed care plan identifying how dementia needs will be managed Specialist advice (geriatrician) Assessment of ongoing need post discharge and discharge planning Staff trained in the management of behavioural problems Liaison support with development of management plan Advice and guidance on de-escalation options Liaison team support for discharge planning Ongoing care after discharge In the acute setting Timely ED/acute assessment Treatment of underlying medical problems Development of management plan, assessing need for specialist nursing or move to appropriate placement Timely liaison input for specialist nursing needs (within a few hours of request) Provision of appropriate inpatient mental health bed if required 16
Regular assessment and review of management plan Medication review Assessment of ongoing need post discharge and discharge planning Staff trained in the management of behavioural problems 7) Information Sharing In order to deliver the highest quality of care and underpinning our model of service delivery outlined is the principle of sharing information and care and treatment plans. It is essential that care and treatment is not delayed or compromised through lack of access to relevant information and/or an absence of joint working. 8) Standards So that we provide high quality services we have developed a set of standards against which we will monitor our service delivery. These standards are divided into those we will meet in community services and those which we will deliver in a hospital setting. There is some overlap across the settings. 8.1 Standards in the community Where a person with dementia is being cared for, treated or supported by services provided Our Standards: Patient Care All patients with suspected dementia (but not diagnosed) will receive a comprehensive assessment All patients with a diagnosis of dementia will have an individualised care plan which addresses their needs in relation to dementia as well as their physical health needs which will be reviewed every 6 months by a member of the MDT All patients with a diagnosis of dementia will have a clear risk assessment and escalation plan detailed within their individual care plan 17
All patients with dementia will have a visual identifier on their notes to ensure staff involved in their care are aware All patients will have This is me completed and available in their care plans All patients with dementia who are approaching their end of life will be flagged to their General practitioner for entry onto the end of life care register Where a patient with dementia is approaching their end of life an appropriate care plan will be developed in conjunction with the patient and their carer/relative Workforce All staff looking after patients living with dementia in the community will have received basic awareness training on dementia 85% of direct care staff will receive more intensive training in caring for people with dementia. All cluster teams will have a dementia champion to ensure the needs of people with dementia are considered in service planning Consideration will be given to employing more staff with mental health experience and qualifications. 8.2 Standards in the acute and community hospital setting The South West Dementia Partnership has developed 8 Standards for care within hospital settings (South West hospital Standards in Dementia Care, February 2011) and it is these that we will use as the basis for our local standards People with dementia are assured respect, dignity and appropriate care Our standards: We will scope the nature and role of ward champions and if appropriate all wards where people with dementia are cared for will have a ward champion. All wards where people with dementia are cared for will have comprehensive literature on the ward for patients and their families/carers All wards where people with dementia are cared for will have individual care plans which address the needs in 18
relation to their dementia as well as their physical health needs All patients with dementia will have an appropriate and individualised risk assessment which will inform their care plan Agreed assessment, admission and discharge processes are in place, with care plans specific to meet the individual needs of people with dementia and their carer/s Our Standards: All patients admitted with dementia (or suspected cognitive impairment) will have a named carer/relative identified in their notes All patients admitted with dementia (or suspected cognitive impairment) will be admitted to the most appropriate ward to meet their needs and where there are staff who are experienced at managing confused and demented patients All patients with dementia (or suspected cognitive impairment) will have a This is me completed prior to any planned admission Where a person with dementia is admitted as an emergency, a care plan will be developed within 24 hours of admission and agreed with the patient and main carer/relative All patients with suspected dementia (but not diagnosed) will receive a comprehensive assessment All carers will receive information about their relative s assessment(subject to appropriate consent) Consideration will be given to whether patients with dementia will have a visual identifier on their notes to ensure staff involved in their care are aware All patients with dementia will be reviewed by the Complex Discharge Co-ordinators (or equivalent role) to ensure appropriate discharge plans are made The Complex Discharge Co-ordinators will hold a register of patients with dementia within NDDH and Matrons will ensure a register of patients is up to date in the community hospitals. 19
People with dementia or suspected cognitive impairment who are admitted to hospital, and their carers/families have access to a specialist mental health liaison service Our Standards: All patients with dementia will be referred to the psychiatric liaison service within 24 hours of admission to NDDH Where a patient does not have a diagnosis of dementia but there are concerns regarding the management of behaviour contact with the liaison service will be made to obtain advice and guidance The hospital and ward environment is dementia friendly, minimising the number of ward and unit moves within the hospital setting and between hospitals Our Standards: We will have clear signage on wards to assist people with dementia, and will use colour and symbols as needed to ensure our environment is fit for purpose If a patient has a diagnosis of dementia they will not be moved between wards unless there is a clear clinical need for their care and treatment With the exception of moves from A&E and emergency treatment no patient with dementia should be moved after 8.00pm at night and prior to 8.00am in the morning The nutrition and hydration needs of people with dementia are well met Our Standards: All patients with dementia (or suspected cognitive impairment) will have a nutritional assessment on admission and prior to discharge Patients with dementia will be supported to have friends/carers/relatives with them at mealtimes to assist Based on their assessed need, if a patient with dementia requires additional support at mealtimes 20
and/or specialist equipment (coloured crockery, utensils etc) this will be provided Patients will be offered the flexibility of adapted diets and finger foods as appropriate. The hospital and wards promote the contribution of volunteers to the well-being of people with dementia in hospital Our Standards: The lead clinician for Care of the Elderly will be the champion for facilitating the use of volunteers within the acute and community hospital settings We will designate a member of our PPI team as a volunteer co-ordinator, which will include volunteers working with patients with dementia The hospital and wards ensure quality of care at the end of life Our Standards: All patients with dementia who are approaching their end of life will be flagged to their General practitioner for entry onto the end of life care register Where a patient with dementia is approaching their end of life an appropriate care plan will be developed in conjunction with the patient and their carer/relative Appropriate training and workforce development are in place to promote and enhance the care of people with dementia in general and community hospitals, and their carers/families Our Standards: All new staff will receive mandatory training through their induction in caring for people with dementia All staff working directly with patients with dementia will have the opportunity to attend basic dementia awareness training 50% of direct care staff will receive more intensive training in caring for people with dementia. 21
9) Delivery and Improvement Action Plan We have based the elements of our Improvement plan on the relevant key objectives within the national strategy and the 8 standards for hospital care in the South West. It is also acknowledged that there are gaps in service provision and NDHT would welcome the opportunity to explore with DCC, NHS Devon and locality commissioners, and DPT how upstream services can be developed to meet the needs of patients earlier in their care pathway, supporting people to remain at home longer and prevent both hospital and long term care admissions. In addition it is clear that further work is required in collaboration with partner agencies to manage the needs of people with dementia in community hospitals where no liaison service is currently commissioned and, to consider how potential service gaps might be addressed in relation to very specialist inpatient care. This is a discussion which has commenced with commissioners and Devon Partnership Trust. It is our intention to continue to work in partnership to pursue improved accessibility of appropriate services. We are developing an Implementation plan which will address the timeframe and actions for completion in order to deliver our strategy. 22