Dementia Pathway 2013 Lincolnshire East CCG Peter Holmes Clinical Leader Boston Locality By 2014, all people with dementia in the UK should be able to say: I was diagnosed early Those around me and looking after me are well supported I can enjoy life I understand, so I make good decisions and provide for future decision making I am treated with dignity and respect I feel part of a community and I m inspired to give something back I get the treatment and support which are best for my dementia, and my life I know what I can do to help myself and who else can help me I am confident my end of life wishes will be respected. I can expect a good death (Prof Alistair Burns, National Clinical Director for Dementia, 2013) Locally, the Lincolnshire Dementia Strategy is beginning a refresh, led by Lincolnshire County Council, and the SWCCG, as lead commissioner for mental health. The principles underlying this work are: People will live well with dementia in Lincolnshire People will remain at home for as long as possible Commissioners will invest in prevention and intervention Commissioners will undertake joint commissioning and develop pooled budgets Stakeholders will provide a positive journey and a pathway to navigate that journey Commissioners will create a sustainable network of services Stakeholders will work together in a trusting, equal partnership Provision will reflect the nature and needs of communities in Lincolnshire
The Dementia Journey Phase 1 Phase 2 When memory problems have prompted me and/or my carer/family to seek help Learning that the condition is dementia Phase 3 Phase 4 Phase 5 Learning more about the disease, how to manage, options for treatment and care, and support for me and my carers/families Getting the right help at the right time to live well with dementia, prevent crisis, and manage together Managing at more difficult times, including if possible to manage at home Phase 6 Receiving care, compassion and support at the end of life http://www.dementiapartnerships.org.uk/commissioning/models-of-care/the-dementiajourney/ The outcomes for Lincolnshire, which are expected include: Improved public awareness of dementia Improved identification and early diagnosis Improvement in the quality of diagnosis Improved quality of care in hospitals and in the community A reduction in the use of anti-psychotic medication More people supported away from Adult Social care and Health Services Improved and accessible information and to enable people with dementia and carers to plan, manage and live well with dementia Reduction in long term care admissions Reduction in hospital admissions due to dementia Improved customer journey and experience Improved support for families/carers that helps preserve relationships Improved outcomes at End of Life Improved access to alternative care pathways Involve people throughout Increase self-management
This will be delivered by a commissioned integrated pathway Delivered via Memory clinic (consultant, psychology services, CPNs ). linked to (possibly embedded) and A new Memory Support Team including dementia and early support workers, CPNs and ( Bromhead ) Nurses / advanced planning team, HIPS / RAID model subdivided into a support team and an advanced team With close links throughout the journey with GPs, LCHS community Nurses, Independent living team, virtual ward, Public Health, social services, 3 rd sector organisations etc. GPs and LCHS staff in particular will be involved throughout the patient journey, but particularly in management of long term conditions, promoting healthy lifestyles, and smoking cessation strategies (with PH and LCC) and in the proactive management of co-morbidities in those with a diagnosis of dementia. Phase one to phase three GP LPFT memory clinic consultant, CPN, Psychology services Memory support team - http://www.dementiapartnerships.org.uk/projects/dementia-support-workers-in-plymouth) - Through an increased public awareness of memory problems currently being driven by PH, patients present to the GP with I have a problem with my memory After appropriate investigation and basic screening has been performed (physical examination, appropriate bloods etc and +/- formal memory testing) all patients will be referred to the memory clinic (LPFT) for formal diagnosis, and a discussion of treatment options and follow up plans for the clinic (not necessarily in hospital setting - discussions about community clinics /practice or locality based clinics will be encouraged - follow up may be via the Community team for those with mild dementia depending on the relationship between the clinic and the community team). At this point the memory clinic will involve the community memory support team - initially by utilising the community dementia support worker (separate service or physically embedded in the memory clinic) in order to, offer advice, signposting to appropriate self help and support services (Alzheimer s society, age UK, SS where appropriate) and will inform the GP Practice and the LCHS practice case manager of the diagnosis and support offered (is this the correct LCHS team member to hold a dementia caseload - we wouldn t expect any pro -active management at this point). This will
enable the practice and LCHS staff to have an accurate register of patients with memory problems, and will prompt and fulfil any need for ILT or other community service involvement at this point. It will also highlight the need to proactively manage co-morbidities. The community memory support team will be the first point of contact for patients and carers for any problems associated with their dementia which cannot be sorted out a practice level with GP and community nurse input. All patients with dementia will have appropriate information (the this is me document) regarding their diagnosis, medication and any care planning details available to them and copies that can travel with them to any appointments or admissions (EMAS will need to know where to look perhaps always on the fridge?) Phase 3-6 management of the decline GP LCHS Memory clinic Advanced memory support team The memory clinic will be expected to monitor those it has diagnosed (by formal testing on a yearly basis or by simple contact?? - either themselves or via the community memory support team) and identify an appropriate time for involvement of the advanced dementia team. This will be prompted by issues such as the need for community support workers going into the home to assist patients and carers, behavioural problems and after any admissions to hospital for whatever reason. The advanced dementia team (CPNs or Bromhead nurses/advanced care planning team) will coordinate care plans, respite care when needed and, ultimately, placement in appropriate nursing care. They will be equipped to offer advice in behaviour management and will have links in to the memory clinic for further advice and help. They will also discuss advanced care planning and end of life care when appropriate. End of life care will involve the advanced dementia team, the GP, and palliative care services in general - and will ensure appropriate terminal care management in a manner and place discussed much earlier in the process. The community memory support team and advanced team will also include workers who can be available to see patients admitted to Pilgrim Hospital AE, CDU or AEC. (able to receive referrals 24/7) in order to co-ordinate care in keeping with an existing care plan (i.e. patients who
have a this is me folder) and to facilitate early discharge. ULHT will need to be aware of the system and to embed the idea of asking about memory. Those who are not known to the team will be referred to the memory clinic (OP if via AEC, seen on the ward if via CDU) who will be expected to do a brief assessment within 24 hrs and to follow the pathway as for any patient referred into the service (Lincoln HIPS. This can / could be done at the point of admission through a RAID type system LPFT have this operating in Lincoln now). So - we would commission a lead provider to construct a memory clinic and a memory support team and to construct the appropriate links with the rest of the system - such as creating the mechanism for ULHT recognising and referring patients, and for EMAS to know how and where to look for the this is me documentation