May 2012 Dr Les Rudd NLIAH & Dr Pauline Ruth ABHB

Transcription

1 May 2012 Dr Les Rudd NLIAH & Dr Pauline Ruth ABHB MENTAL HEALTH 1000+LIVES TARGETS Improving Care for people living with dementia Insert name of presentation on Master Slide

2 Knowing is not enough; we must apply. Willing is not enough; we must do. - Goethe

3 Houston, we have a problem We are here because: PRINCE Project Management Targets Performance Management alone doesn t work Lives Plus

4 Different types of targets Current Targets Perversity Imposed targets Lovely targets but no change Focus on service model not process of change Intelligent Targets Local targets relative advantage Trialability - Observability Focus on process of change Use expert groups for subject knowledge

5 What are we trying to do? Improve the reliability of care in Wales sustaining improvement Raise the standards of care in Wales Promote evidence based practice NICE compliance Establish effective / reliable outcome measures that make sense to clinicians (face validity)

6 1000+Lives improvement measures in mental health Depression in General Hospital settings First Episode Psychosis Eating Disorders Dementia 1) making and sharing the diagnosis reduce time between onset of symptoms & diagnosis being communicated 2) dementia in the general hospital Improved quality of general hospital care for people with dementia and reduced length of stay 3) use of anti-psychotics Reduced inappropriate use of anti-psychotic medications in accordance with NICE/SCIE guidelines. 4) support for care-givers Improved support for care givers 5) NHS in-patient care (mental health units) Improved quality of care

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8 1st April Letter to CEO s As you know, one of the aims of our mental health standards is to drive more effective integration of physical and mental health care, such as where we have evidence of increased lengths of inpatient stay due to co-morbidity. This is a particular feature of the depression and dementia standards, which include a focus on improving early diagnosis/case identification, treatment and care in General Hospital ward settings. We are experiencing difficulty in some localities in accessing General Hospital wards to pilot our mental health standards and I would appreciate your support in prioritising access. Note: Could you therefore forward this letter to your Medical Director and 1000Lives Executive leads to help action this with your mental health clinical leads.

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10 Tools for improvement: Data tools: Team tools: Action tools: Run Charts Team assessment PDSA s Schewart Charts Process mapping SBAR Frequency Plots Learning sessions How to guides Pareto Charts Team meetings Posters MONITOR WILL/IDEAS EXECUTION 1000 Lives Plus

11 Collaborative Improvement Model Repeated improvement cycles: planning testing evaluation sharing implementing Repeated improvement cycles: planning testing evaluation sharing implementing Repeated improvement cycles: planning testing evaluation sharing implementing Planning Learning session 1 Learning session 2 Learning session 3 Support systems 1000 lives support team Interactive learning sessions Inter-clinic communication (e.g. monthly meetings) Continuous feedback (sharing data)

12 Rhyngrwyd/Internet: Mewnrwyd/Intranet: nww.publichealthwales.wales.nhs.uk Twitter:

13 Improving Care For People Living With Dementia Dr Pauline Ruth CD, OAMH, ABHB 10 th May 2012

14 Demography (WHO, 2012) 35.6 million people world wide doubled by 2030 tripled by 2050 huge impact on individual, family, society action needed nationally/internationallyevidence, equity, inclusion and integration

15 Culture Of Care (Tom Kitwood) institutional biomedical, task driven, ignores lived experience person centred - value driven, well being and empowerment, observation and feed back

16 Current Training 52% of nursing staff in General Hospitals have no work based training in dementia care more than 1/3 of dedicated dementia care homes have no specific dementia training

17 Challenge how to translate core competences into practice in institutional settings such as General Hospitals and Care Homes

18 Background National Dementia Audit (2010) Dementia care delivery planning advice ( ) Intelligent Targets (2010) Vision for Wales (2011) everybody s business

19 First Steps (ABHB) development of 5 multi agency IT working groups meeting monthly identification of champion and pilot sites interface with NLIAH/1000 Lives helpful - AWIN meetings, dementia WEBEX

20 Intelligent Target 2; to improve care on general hospital wards pilot site Ward C7E RGH champion Vicky Williams Brecon and NH hospitals quick adopters

21 PDSA Cycle admissions survey dementia/delirium adapted admission sheet liaison nurse training recognition of cognitive impairment care plan for delirium mild cognitive impairment pathway

22 PDSA Cycle cont This is me life story book HCA s and informants Dementia friendly environment activities box roll out learning This is me

23 Intelligent Target 3; to improve community care (including care homes) anti psychotics audits of antipsychotic prescribing in care homes in Newport, Caerphilly, Torfaen and South Powys

24 Results high levels of prescribing/poor compliance with monitoring standards in-reach nurse Caerphilly- training and medication reviews - reductions in antipsychotic prescribing, efficiency savings, improved patient care responsibility (GP, care home staff, community pharmacy, specialist services) often unclear

25 Actions taken guidance - managing behaviour that challenges and alternative interventions (intranet) check list - initiation and review of antipsychotics in dementia (intranet) use of antipsychotics in dementia patient/carer information leaflet (intranet) consent/capacity/best interest assessment introduced into antipsychotic pathway medicines management antipsychotic work and this driver combined (joint database)

26 Monmouthshire EMI Nursing Home Psychotropic Prescribing Audit concern that antipsychotics tip of iceberg 40% of prescriptions in nursing homes may be inappropriate anxiolytic/hypnotic use a major concern world wide with high risk of side effects such as falls prescribers may switch

27 Aim to ascertain whether psychotropic prescribing in EMI nursing homes in Monmouthshire is in keeping with guidance antipsychotics, antidementia, benzodiazepines, z drugs, antidepressants, mood stabilisers

28 Method retrospective review of case notes primary and secondary care, community pharmacy and care home involvement of community pharmacy and NCN lead for dementia approximately half residents with dementia under primary and half under secondary care

29 Results 139 residents with dementia 23% - no psychotropic 33% - one 26% - two 18% - three or more

30 Prescribing Pattern 60 antidepressant antipsychotic benzo 30 z drug 3-D Column 2 20 antidementia 10 0 mood stab

31 Compliance with Guidance High Low Antidepressants Antidementia Mood stabilisers Antipsychotics Benzodiazepines Z drugs

32 Antipsychotics 82% - more than 3 months 19% physical causes ruled out 15% documented risks discussed 8% capacity assessed staff not trained in dementia, medication or side effects

33 Recommendations Individualised psychotropic prescribing and monitoring passport to be held at the care home start date, prescriber, frequency of reviews, reviewer, next review date, side effects

34 Recommendations cont monitoring agreements to be developed between primary and secondary care, community pharmacy and care home staff inreach service to support training

35 What We Really Need time and motion study of staff going into care homes, who goes, how often, what skills they have, what information they keep, who they communicate with and what actions they take

36 PDSA Strengths Weaknesses small achievable steps highlights champion and quick adaptors engages the whole team learning/change integral to process continuously evolving sustainable single site/small scale depends on workface leadership roll out slow/snails evidence lacking focus maybe misplaced outcome uncertain

37 Audit Strengths Weaknesses comprehensive baseline data what/who/when/why brings together partners believed in by professionals highlights poor performance focus maybe misplaced maybe unidisciplinary multiple information systems time consuming ownership unclear critical rather than enabling no clear action plan rarely reaudited

38 Change Culture need both fact finding audit and PDSA PDSA cycle particularly effective at changing the culture on the ward, led from within all staff have two jobs to do the job and to improve it