Improving Oral Health for Older People Living in Care Homes in Wales

Transcription

1 Improving Oral Health for Older People Living in Care Homes in Wales Welsh Health Circular/2015/001 A summary of delivery from 1 April 2015 to 31 March 2016 Lisa Howells Chair of National Advisory Group (Deputy Chief Dental Officer, Welsh Government) August

2 Improving Oral Health for Older People Living in Care Homes in Wales WHC/2015/001 A summary of delivery from 1 April 2015 to 31 March 2016 Introduction Welsh Government (WG) issued Welsh Health Circular WHC/2015/001 in February Improving Oral Health for Older People Living in Care Homes in Wales. The WHC included a total annual recurrent funding of 249,750 to be shared across 7 health boards. The WHC can be accessed at this link: The purpose of the WHC was to provide information, detail of Welsh Government policy and available funding to deliver improved oral health for older people living in care homes in Wales. In this context care home encompasses both nursing and residential homes for older people including those for people living with dementia. The focus is on ensuring residents have an oral risk assessment, and an individual care plan to optimise oral hygiene and reduce the risk of additional disease. The key aim of the programme is to improve oral hygiene and mouth care for older people living in care homes through the development of a consistent all-wales approach. Health Board Annual funding Funding criteria, based on the number of care homes in each health board area. Aneurin Bevan 38,110 Abertawe Bro Morgannwg 38,480 Betsi Cadwaladr 80,290 Cardiff and Vale 24,420 Cwm Taf 19,610 Hywel Dda 37,000 Powys 11,840 Total committed expenditure 249,750 A website has been established which includes the WHC and a wide range of information to support delivery of the programme, including a How to Guide. The principle is that the work will be led by care homes and supported by Community Dental Service (CDS) dental teams. However at this early stage the programme delivery is largely the responsibility of the CDS who were asked to submit data and a short written report on the first year s activity to the Welsh Oral Health Improvement Unit (WOHIU). All CDSs submitted data and reports on time and used the template format. 2

3 Baseline Summary of work prior to WHC/2015/001 From the outset it was acknowledged that health boards are at different stages in delivering mouth care in care homes, and therefore progress in introducing the new programme will differ across Wales. WG did not expect all care homes to implement the programme immediately, but the intention is that all care homes should be participating (or have been invited to participate) by 2018 in line with health board delivery of their Local Oral Health Plan (LOHP). In addition Local Implementation Groups (LIG) are required to ensure the work is evidence based and implemented using recognised improvement methodologies. These improvement methodologies are aligned to 1000 Lives Service Improvement and underpin the way in which the programme is developed and rolled out. The CDS descriptions of past activity identify thoughtful reflection on achievements (or lack of progress) and generally welcome the introduction of WHC/2015/001. A wide variety of work was undertaken across Wales prior to WHC/2015/001 but it was patchy and not underpinned by a consistent all-wales approach to any aspects. However, past activity provides valuable lessons for the future and it is important to build on this learning. Past activity included: Specific training for staff who work in care homes; Including care home staff in other training programmes (e.g. Palliative oral care skills); Training for other groups such as Care Home Managers, Third Sector organisations, local authority teams and other health professionals; Development and testing of locally developed risk assessments and care plans, with subsequent use in care homes who expressed an interest; Liaison with health board nurse teams who work with local nursing homes; Use of resources available from expert organisations such as British Society of Gerodontology; Well established local programme in North Wales - Gwên am Byth - and existing programme in Aneurin Bevan health board and Cardiff and Vale/Cwm Taf health boards; and Varying levels of clinical input to care homes by both CDS and general dental practitioners. The current evidence base shows that staff training alone does not improve oral care for people living in care homes. It must also include use of recognised and validated risk assessments and care plans, be underpinned by clinical leadership in the care home and supported by suitably experienced dental teams. National Advisory Group As per the WHC, a multi professional, multi disciplinary National Advisory Group has been established to oversee and guide delivery. The group has agreed to meet twice 3

4 a year and brings together representatives from Care Homes, the dental profession and other heath professions. The group acknowledged that health boards have different systems for risk assessment and care planning and these would guide development of principles to underpin documentation across Wales. However, the Care Home representatives later gave a very clear steer that Wales should have all-wales risk assessments and care plans, so the Task and Finish Group is now working toward this. The Task and Finish Group As per the WHC, a Task and Finish Group has been established to identify suitable resources that can be used in Wales, or develop resources where suitable ones are not available. The T&F group meets at least quarterly and includes representatives from all CDS in Wales. The group has worked effectively to identify/develop: a model policy on oral care in care homes for local authorities and health boards, to inform contracts with care homes; examples of oral care policies for care homes; examples oral risk assessment; example care plans; advice on evidence based practice and appropriate resources for oral hygiene; and guidance on the content of training programmes for care home staff and Oral Care Champions. As per use of National Improvement Methodologies, these resources must be tested and amended to ensure they are fit for purpose before they are used. This detailed preparatory work is not captured in the data provided by health boards, but it is essential if the programme is to be implemented effectively. The Task and Finish Group are using experience from the 1000 Lives programme to improve mouthcare for patients in hospital to develop resources that promote consistent standards of care for people who live in care homes but may require hospital care. Use of Resources new staff employed WHC/2015/001 noted that Funding could be used to employ a CDS dental team member to support programme delivery, provide training, liaise with care homes and provide hands on support to care home staff as they start to use the risk assessment and implement care plans. Some CDS have employed new staff members or used funds to increase existing staff capacity New health board CDS staff have been employed in: ABM - Oral Health Promotion Officer, 1 WTE AB - Oral Health Improvement Practitioner, 1 WTE 4

5 C&V and Cwm Taf - 2 Dental Health Improvement Practitioners, 0.56 WTE; and 1 admin support, 0.2 WTE Powys - Dental Therapist, 0.4 WTE BC - additional Therapist sessions with planned recruitment of at least 2 Oral Health Educators Hywel Dda - 1 WTE Medical Secretary and Administrator employed which released 1 WTE Dental Nurse to support delivery of the WHC In addition a small number of existing CDS staff have changed their roles to include delivery of the programme. Resources have been purchased to support programme delivery including IT equipment and visual aids to support training. In addition CDS staff form the core membership of the Task and Finish Group and their work is a necessary pre requisite before implementation of the programme in care homes. Local Implementation Groups WHC 2015 / 001 required health boards to establish a Local Implementation Group (LIG) to plan delivery ensuring stakeholders are provided with opportunities to contribute effectively. All health boards have established their LIG. Reflecting its geographical size, BC has established a LIG for each of their 2 pilot areas in Gwynedd and Anglesey, and these are overseen by a single Regional Strategic Planning Forum ABM has established 3 Task and Finish Groups to support local development and delivery of specific aspects of the programme Membership of the LIGs generally follows the outline in WHC/2015/001 but there has been innovative inclusion of others members reflecting the need for additional expertise and guidance. Examples of additional members include: Local Dental Committee representative; Speech and Language Therapist; Pharmacist; Dietician; Dental Academic; A range of health board nurses; and Senior managers in the health board Delivery to Date Data provided by the CDS is shown in Annex 1. The data provided reflects the programme is at an early stage. In summary the data for Wales shows that: 5

6 15% of care homes (n= 108) have been targeted to participate in the programme Of the targeted care homes; - 5 are not yet participating, 86 are participating in part and 17 are participating fully - 92 have an up to date mouthcare policy - 92 can identify local dental services available to their residents - None of the targeted care homes have yet had an external inspection which included aspects of mouthcare training sessions have been provided by CDS staff to 1338 care home staff - 50 oral care champions have been trained by the CDS, although these champions have not yet trained staff in their care homes (this is to be expected at this stage of the programme) - Of the 3723 care homes residents, a total of 110 (3%) have had a risk assessment and 133 have a mouthcare plan which is being delivered. CDSs in Wales are at different stages in their pre WHC/2015/001 work with care homes and this will be reflected in the pace with which the work spreads across individual health boards. The data shows the CDS have followed national improvement methodologies and mostly started the programme in a very small number of homes. Aneurin Bevan, Cardiff and Vale / Cwm Taf data reflects a level of previous activity in care homes. WG expect the CDS to use the principles of service improvement as defined by 1000 Lives Service Improvement. As a general rule this means to start small and spread the work step by step as new ways of working become consistently embedded and capacity allows. Those CDS where the programme was starting from scratch were advised to select a home/homes where staff are committed to improving oral health for their residents to facilitate learning from what works well (and less well) in implementing the programme. Barriers to Implementation The most common barrier to implementation was the ability to recruit suitably trained and experienced staff to support programme delivery. In some cases recruitment was considerably delayed by health board internal processes. However new staff have been recruited and are reported to be taking forward the programme with skill and commitment. Other barriers have been identified in some care homes: staff capacity and resources; shift working; staff with limited use of the English language; high rates of staff turnover; 6

7 a belief that the process will be onerous or used as a performance management tool; the proposed risk assessment and care plans do not align with existing processes (e.g. in care homes with UK wide processes); and a reluctance to become Oral Champion without additional rewards. It is recognised that some residents may have challenging behaviour related to a health condition which limits their ability to co-operate with the risk assessment and delivery of the care plan. The two Public Health Wales Consultants in Dental Public Health have limited capacity to support the programme at health board level, although they are providing advice as requested. Examples of Good / Innovative practice There are already examples of good / innovative practice including: use of Dental Care Professionals (DCPs) to lead programme delivery and implementation (in line with prudent health care) integration of the programme into LOHP and Integrated Medium Term Plan joint working across health boards oral champions requesting badges to identify their status as taking a lead role a nurse working in a care home chose to focus on oral health as part of her RCN leadership programme marking dentures with residents name has been welcomed (this is offered where CDS capacity allows) Next Steps Health boards are sharing experience formally through the National Advisory Group and the Task and Finish Group, as well as informally by personal contact. This supports consistent programme delivery and reduces unnecessary repetition of development of all Wales documentation The all Wales documentation should be developed and tested to be ready to implement in late The CDS will continue to accelerate the roll-out increasing the number of care homes participating and residents assessed. We reasonably expect about 30% of homes across Wales to have been targeted by the end of March 2017 with at least 25% of their residents having been risk assessed Acknowledgements Welsh Government would like to acknowledge: the commitment and skill of all those who are delivering the programme, in particular the CDS, health board nurse teams and other stakeholders: 7

8 Maria Morgan, WOHIU, who supported development of the data collection system and collated and presented the data: and Members of the National Advisory Group and Local Implementation Groups. Lisa Howells Chair of National Advisory Group August

9 Annex 1: CARE HOME REPORT TABLES AND FIGURES 2016 DEMOGRAPHICS Figure 1 Number of homes targeted compared with total in LHB, as at March 2016 Figure 2 Participation status of those homes targeted LHB % TARGETED ABMU 6% Aneurin Bevan 44% Betsi Cadwaladr 4% Cardiff & Vale 33% Cwm Taf 25% Hywel Dda 2% Powys 16% WALES 15% 9

10 Table 1 Policies Total number of homes as at 1st April 2015 Number with an up to date mouthcare policy Number homes who can identify their local dental services % with an up to date mouthcare policy % homes who can identify their local dental services ABMU % 0% Aneurin Bevan % 36% Betsi Cadwaladr % 4% Cardiff & Vale % 33% Cwm Taf % 25% Hywel Dda % 2% Powys % 16% WALES % 13% Table 2 Inspections LHB How many have had an external inspection or review during the reporting period which has highlighted good / excellent mouthcare? How many have had an external inspection or review during the reporting period which has highlighted inadequate mouthcare? ABMU 0 0 Aneurin Bevan 0 0 Betsi Cadwaladr 0 0 Cardiff & Vale Don't know. WG care home data tool not currently in place Cwm Taf Don't know. WG care home data tool not currently in place Hywel Dda 0 0 Powys 0 0 WALES

11 CARE HOME STAFF Table 3 Training LHB Number of health and care staff eligible for training Oral health champions trained (by the CDS) Number of health and care staff trained by the CDS (not including OC) Number of staff trained directly by oral health champion Number of sessions training given to care home staff by dental team ABMU Aneurin Bevan Betsi Cadwaladr Cardiff & Vale Cwm Taf Hywel Dda Powys WALES CARE HOME RESIDENTS Table 4 Care Home Residents assessments and care plans CARE HOME RESIDENTS in homes particpating fully LHB Total number of residents Total number of residents risk assessed Total number residents who have a Mouth care plan ABMU Aneurin Bevan 1686 data not collected yet Total number residents who have had their mouth care plan delivered 0 Betsi Cadwaladr Cardiff & Vale 1044 Don't know. WG care home data tool not currently in place Cwm Taf 628 Don't know. WG care home data tool not currently in place Hywel Dda Powys WALES