Memory & Later Life services

Transcription

1 Memory & Later Life services

2 Brief Background: Huge changes in population within Cumbria Almost doubling of dementia Extremely rural geography with challenges to provide services

3 Key Factors of Success Person centred focus to redesign Impact & results Teamwork inspiring change

4 Redesign of services by Care Elements Development & Implementation of Care Pathways- with staff focussed on specific roles- Early memory Complex Needs CHESS (Care Home) Redesign of services matched to need

5 Virtual Memory Clinics Designed around person centred diagnosis Enhanced initial nurse led assessments Diagnostic discussion Diagnosis feedback to patient/family by same person who assessed Family based interventions then taken forward with psychosocial approaches and carer intervention

6 Impact & results Memory Matters: Carlisle has effectively brought together varied strands of Care Elements focussing on the person and their families experience Early Diagnosis and Virtual Clinics: Despite huge rise in referrals- reduced waiting time by 60% with consultant efficiency improved by 300%. Full MDT assessment and interventions service based on person s experience Improving understanding of Dementia: Delivery of dementia training, joint working and implementation of a screening too across a variety of settings 794 staff trained in screening tool

7 Family interventions: Delivery of family interventions and proactive carer support-embracing the 6 C s approach (Our Culture of Compassionate Care) and includes routine assessment of all carer s. Psychosocial Carer interventions Carer needs identified, access to mainstream services including education, peer support, respite Signposting to written information, support and advice through Third sector services and community based support

8 Longer term care: This innovative arm of the service combines a rolling programme of education, together with a time limited outreach service to work alongside Care Home staff, modelling interventions and aiming to improve skills and awareness. Admissions from care homes have fallen from 52% to 4%- this demonstrating the effectiveness of this approach.

9 Local GP I would say that my experience of the virtual dementia clinic has been very positive with patients being assessed by a nurse very promptly. I feel that this is a much more appropriate situation than huge waiting lists to see a consultant. I have had good feedback from patients and their families with regards to this system and how it is functioning and given the increase in numbers and the increase in publicity surrounding dementia we are getting more and more patients who are needing referral. Patient I appreciate the care and consideration from all the staff I encounter in both the memory clinic and in the team visiting me. Thank you so much. I feel more hopeful and still able to enjoy what matters most to me.

10 Carer: I was very impressed by the professional manner in which all interviews were carried out and the compassionate way information regarding this illness was communicated to my father and us as family members. It was also so reassuring the way we felt listened to and able to think about what this diagnosis might mean to us as family. We felt much more confident with the support going forward.

11 #seetheperson aimed to energise, enthuse and focus staff across Memory & Later Life Mental Health Services on the values of Person Centred Care and Recovery; that this underpinning value is central at individual, team and service level and that this service line approach is dedicated to promote the person at every stage. The need to improve patient experience, raise standards of quality and safety and focus on the person is the foundation of this project. #seetheperson concept aimed to move the focus of care away from mainly concentrating on a person s diagnosis or symptoms by instead focussing on all the persons needs and importantly considering what is important from the persons perspective. This also includes enriching the involvement of carer s and families where appropriate.

12 Moving Forward in One Team #seetheperson has effectively connected varied services around the person and their family With wellbeing & Quality of life the main focus of care- services connect and work closely as a team to protect this. Creative and compassionate principles underpinning this project now connecting across Cumbria's rural geography- taking advantage of this rather than being challenged by it. Joint working now central with connection across Cumbria enthusing staff to contribute and make a difference

13 Conclusion Taking forward this ambitious development has enabled the service to really make a difference in improving clinical quality by focussing on the needs of the individual, enabling their carer s/families and/or supporters to remain fully connected to the person s quality of life and enable staff to feel increased value. The development has enabled services to work effectively with a dramatic increase in quality, flexibility and joint working across settings- all focussing on supporting the person.