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Faithworks Wessex Early lessons from the Poole Integrated Care Pilot Matt Thomas Consultant Physician Dept of Medicine for the Elderly Poole Hospital NHS.

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Presentation on theme: "Faithworks Wessex Early lessons from the Poole Integrated Care Pilot Matt Thomas Consultant Physician Dept of Medicine for the Elderly Poole Hospital NHS."— Presentation transcript:

1 Faithworks Wessex Early lessons from the Poole Integrated Care Pilot Matt Thomas Consultant Physician Dept of Medicine for the Elderly Poole Hospital NHS Foundation Trust

2 Faithworks Wessex Early lessons from the Poole Integrated Care Pilot Matt Thomas Consultant Physician Dept of Medicine for the Elderly Poole Hospital NHS Foundation Trust


4 Faithworks Wessex INTEGRATED CARE PILOT OVERVIEW The pilot will test a new model of GP locality integrated dementia services. The ambition is to integrate not only with traditional health and care agencies, but to become established and known within the wider community to improve access for people with memory impairment. Two new care services for people with memory loss and dementia will be delivered by a joint multi-disciplinary team. This will provide high quality, person centred, specialist care.

5 Faithworks Wessex KEY FEATURES OF THE PROJECT: Aligns to the National Dementia Strategy and the associated local dementia care pathway. Will deliver Early Intervention Services and a Specialist ‘Crisis and Home Support Team’. Focuses on the locality of Westbourne. Targets ‘non-traditional’ hard to reach groups. Experiments with solutions to local challenges (e.g. LA boundary issues, development of PBC, developing the market, etc.).

6 WHAT WILL BE INTEGRATED? Patient Faithworks Wessex


8 Faithworks Wessex

9 Age standardised hospital admission rates for all psychiatric diagnoses, 2003-2005 0 100 200 300 400 500 600 700 123 Admissions per 100,000 persons Bournemouth UA (persons) Poole UA (persons) Bournemouth and Poole PCT England (persons)

10 Faithworks Wessex


12 LOCALITY GP PRACTICES INVOLVED Case finding will take place using the vulnerable adults and carers registers. Potential service users will be identified using a network of organisations who come into contact with people living independently in the community (e.g. community pharmacists, emergency services, third sector, local services, etc.).

13 DEMENTIA PATHWAY NICE guidance no longer met Memory Clinic AD confirmed NICE met Non Alzheimer’s dementia No unresolved physical or psychological problems MMSE >21 No unresolved physical problems but with psychological/ behavioural problems MMSE <21 Shared Care as per NICE CMHT for assessment and monitoring as appropriate Probable AD? NO and/or other MH problems YES New psychological or behavioural problems with no physical cause Review 6 monthly PRIMARYCAREWITHMANAGEMENTPLANPRIMARYCAREWITHMANAGEMENTPLAN GP/C of E Physical examinations Investigations MMSE COGNITIVE IMPAIRMENT Non-medical support team within community to meet lifestyle needs of the three identified groups of people and their carers at any point on the pathway AD diagnosed in CMHT © P French 2008 CRISIS AND DISCHARGE SUPPORT TEAM* *taking referrals from CWs in Dementia Support Team, acute Trusts (elderly wards and intermediate care AD confirmed NICE not met

14 Faithworks Wessex OUTCOMES OF THE PILOT: A fully integrated service aligned to the GP localities. No boundaries between older people and older peoples mental health services. An integration model that moves beyond co-location of health and social services staff into single line managed teams, with voluntary sector staff. A range of new locally based, low level interventions for people with memory loss and their carers will be in place. Interventions that can be accessed as a consequence of GP referral, but also serve to signpost to GP’s, when memory loss is becoming apparent.

15 Faithworks Wessex A single access point in a crisis to a fully integrated Crisis and Home Support Team within their locality, which contains specialist staff to respond specifically to the needs of people with memory loss / dementia. Extended roles that stretch professional boundaries (e.g. health care workers to undertake Mini Mental Evaluations - MMEs). Evidence of higher levels of confidence being expressed by service users themselves, or their carers, of enabling them to remain within their own home. A fully engaged / dementia aware community. OUTCOMES OF THE PILOT:

16 Faithworks Wessex PERFORMANCE MEASURES: The project performance analyst will track: Financial measures (e.g. unit costs). Productivity (e.g. patients seen, response times). National health & social care KPIs (N125,etc). Benchmarking (vs. outcomes in the other 6 localities). Quality (audit, survey, complaints and compliments).

17 Faithworks Wessex PROJECT PLAN

18 Faithworks Wessex COST OF THE PILOT


20 Faithworks Wessex IMPLICATIONS FOR THE WORKFORCE Established local framework for delivering integrated services. TUPE & ‘Retention of Employment’ will not apply. There will be a partnership framework. This will be managed using a host budget (held by the NHS). Formal secondments & rotational posts will be used. Professional needs / support will be considered when deciding who the employer will be of each role. Staff with the same role, may have different employers (e.g. Care Assistants can either be on an LA employment contract or an NHS contract) but T & C will be equitable. HR department will ensure legal and policy requirements are met. Approach approved by Tim Sands, Deputy Director Pensions Policy.

21 Faithworks Wessex DELIVERY MODEL The integrated team will have an office base in the Lilliput surgery. Services will be delivered in community sites and in patients own homes. GPs and patients will have a single referral telephone number. Emphasis on seamless service for patients (despite the boundary issues with different local authority).

22 Faithworks Wessex CRISIS & HOME SUPPORT TEAM The objectives of the team are that: To avoid unnecessary hospital admissions for people with a mental health illness. To provide urgent response, short interventions to support carers in crisis situations and to prevent carer breakdown situations. To expedite discharges from hospital for people with a mental health illness. Patients with memory loss/ dementia, receive person-centred care.

23 Faithworks Wessex Interventions usually for less than 2 weeks. Available between 7am and 10pm, 7 days a week. Resourced by community mental health nurses, specialist trained crisis and home support assistants, a social worker and medicines management. Will have access to consultant advice from a geriatrician and a psychiatrist. Will be able to link into the generic services as appropriate. Will have pro-active crisis planning to support their work in advance where possible. CRISIS & HOME SUPPORT TEAM

24 Faithworks Wessex LOW LEVEL SUPPORT SERVICES A dementia advisor will support people throughout their illness to: Provide advice to keep people active and well. To encourage the people to maintain the lifestyle, practices, and choices that they had prior to having the disease to the fullest extent possible. To draw up emergency plans in preparation for crisis situations.

25 Faithworks Wessex New signposting and support services for people with memory loss and their carers provided through the creation of Dementia Cafés funded by social services and operated by Alzheimer's society. Reconfigured floating support services for people with memory loss to give specific focus on the Westbourne locality. Rethink team leader physically located within the team office and working as part of the integrated team. Faith based and voluntary organisations within the locality equipped to provide information and signpost people with memory loss to the integrated team. LOW LEVEL SUPPORT SERVICES

26 Faithworks Wessex PARTNERSHIP – LOCAL AUTHORITIES Integrated team supported by virtual team of Dorset Fire and Rescue Services, Housing Services, Culture and Learning, Arts Development. New well check service (commences July 09) to adopt specific protocol for people with memory loss. Joint contract with Rethink for floating support services. Established pattern of joint working.

27 Faithworks Wessex PARTNERSHIP – THIRD SECTOR Third sector organisations i.e. Rethink, Alzheimer's Society and Faithworks Wessex to form part of governance arrangements. Rethink team leader physically located within team office. Alzheimer's society dementia advisor located within team office. Operational single line management to operate across all posts.

28 Faithworks Wessex PARTNERSHIP – COMMUNITY PHARMACY 7 Community pharmacies in the locality. Two will participate in the pilot. Westbourne and Canford Cliffs (main shopping areas). Will case find to signpost to the dementia advisor and to low level services. Provides potential to expand the role of community pharmacists further (e.g. undertaking MMSE tests, etc).

29 Faithworks Wessex PARTNERSHIPS TO BE DEVELOPED Libraries Local shops Ambulance Fire Police

30 Faithworks Wessex PATIENT INVOLVEMENT Dedicated steering group of people with memory loss to be established. Dedicated steering group of carers to be established. Both groups to be involved in service monitoring and ongoing service design as per existing model operating in Poole Intermediate Care Services.

31 Faithworks Wessex PROJECT GOVERNANCE Accountable Project Director - NHS Community Health Services, Deputy Director. The Project Manager - will report to the Accountable Project Director and to the Project Board. Locality Steering Group (LSG) - locality lay people, professionals, commissioners and partners who will ensure project objectives are met. Joint Commissioning Executive Group (JCEG) - will consider joint strategic issues, which could impact the project. Business Manager / Performance Analyst - track / monitor deliverables.

32 Faithworks Wessex OPERATIONAL GOVERNANCE Accountable Deputy Director. Regular operational and performance meetings with partners. Professional Line Management - of all staff and volunteers. Align to National Dementia Strategy / NSFs / LDP. Operational policies and procedures documented. Mental Capacity Act & Adult Protection training evidenced. Risk management procedures in place. Robust financial management. Performance monitoring.

33 Faithworks Wessex SUSTAINABILITY There are seven localities in Poole and Bournemouth. The pilot can be commissioned / replicated in the other 6 sites. This approach has already been used to implement other initiatives - e.g. Poole Intermediate Care Services and the Bournemouth Community Assessment and Rehabilitation Team). Financial stability / consistent performance of all partners. There are excellent relationships between the partners. PBC is developing and strengthening the relationships between GPs and providers.

34 Faithworks Wessex THE PILOT WILL SUCCEED BECAUSE: It will have continuous user involvement from the outset through the LSG. It extends a successful model already adopted within intermediate care. It will be professionally project managed. The pilot fits within the local and national strategies. The outcomes are based on extensive research. The joint commissioners / PBC are supporting this. The professionalism / commitment of the clinicians and the team.

35 Faithworks Wessex QUESTIONS?

36 Faithworks Wessex Lesson 1 When is a pilot not a pilot? –Enthusiasm can pre-empt assessment of outcomes. –Roll out regardless.

37 Faithworks Wessex Lesson 2 A stitch in time saves nine –Best plans are those where there is engagement early on

38 Faithworks Wessex Lesson 3 New methods of working don’t mean new methods of diagnosis (EBM) –Still need to use ICD 10

39 Faithworks Wessex Lesson 4 Definitions –Early diagnosis Vs first presentation of late diagnosis

40 Faithworks Wessex Lesson 5 Use the 3 rd Sector

41 Faithworks Wessex Lesson 6 Use what you have got PICS

42 Faithworks Wessex Case history 1 Mrs H referred by GP to ICP re poor STM. Presenting problem: Lives alone. No family. Aware of poor short term memory but not to true extent. Thought she would sell flat as needed residential care as didn't know how she would cope. Not known to any other professional

43 Faithworks Wessex Pt Seen: Basic physical health screening completed, Full dementia blood screen, urinalysis, BP, BM etc all NAD RMN completed full mental health assessment. (very poor cognition identified) ICP ICAs in place daily re poor self care and promoting independence ICP dementia support worker in place and initiating weekly 1-1 engagement re life diary/history. (long term involvement and future single point of contact) Referred to Rethink floating support re managing bills/finances (in a muddle) Advised GP to refer to memory clinic with copy of assessment re diagnosis (?Probable Alzhiemers) and MMSE within NICE guidelines for consideration of antidementia drugs.

44 Faithworks Wessex Probable outcome: promoting independence and hopefully remaining at home for longer as services in place to monitor health and well being

45 Faithworks Wessex Case 2 Mr S 93yr old man referred by GP to ICP RMN. Presenting problem: Wife died 2 days prior to referral. Family concerned re poor STM and current managing of personal care. Pt Seen: Basic physical health assessment, bloods etc all NAD Baseline MMSE 27/30. Suspicious ideas concerning family and money evident. ?Acute grief reaction. Also had just come to light his wife had left high amount of money in her will he knew nothing about...?adding to confusion and precipitating suspicious ideas Capacity assessment (although high scoring MMSE completed due to presenting problems with memory recall)

46 Faithworks Wessex Decision specific to moving to residential care (pre planned move to Jewish home that his sister resides in) Family had organised move but Mr S refusing to go until affairs sorted out at home. Assessed has having capacity by SW and RMN Agreed to ICP ICA input to support current grief process Emergency OOH admission to PGH prior to ICA input with chest pain. Physical tests NAD. RMN referred to in-pt psych team for review of mental health due to familys current concerns re presentation and him returning to his home (even with ICP ICA support) Seen by in-pt psych and suspicious ideas noted but unclear cause. Probable Acute grief. Discharged home with planned ICP support.

47 Faithworks Wessex Day following discharge phonecall to RMN from ICA to say appearing physically unwell. Home visit immediately by PICS On call consultant and RMN. Family also present and Mr S stating he wanted to go to the residential home to be cared for. Made decision himself and family arranged. Appeared sad and anxious. SW followed up in residential home. Suspicious ideas remained re family and money. SW arranged to meet with his solicitor 26-10-2009 and Mr S to go through his money situation. Mr S aware and appeared to take on board and SW felt he was reassured by this.

48 Faithworks Wessex 24-10-2009. absconded from residential unit. Police informed as missing person. Police found him at home with a suicide note and an empty bottle of whisky Taken to PGH. seen and discharged same day. Readmitted 25-10-2009 with chest pain. RMN referred back to in-pt psych 26-10-2009 who re assessed and was found to be psychotic and now deemed sectionable. Now on antipsychotics. Deemed significant suicide attempt but fortunately passed out prior to drinking his pre-prepared cocktail of kitchen cleaners.

49 Faithworks Wessex Case History 3 Miss S referred by GP re poor STM No other professional involvement apart from cardiologist Ongoing physical health problems re heart.

50 Faithworks Wessex Full assessment by RMN 30/30 MMSE 92/100 Addenbrookes Engaged well and presented well until i asked her to do a GDS. totally flummoxed by it and scored 7/15 (worthless, helpless, life not worth living etc) Symptoms all coincide with low mood, probably precipitated by social isolation as fell out with her 2 friends last year and hasn't been out.

51 Faithworks Wessex Outcome Referred to Age concern re social activities Referred to Age concern re befriender Referred to ICP memory support worker RMN to monitor mood and behaviour and repeat GDS in 4 weeks and if no improvement liaise with GP re antidepressants. If memory symptoms worsen GP to consider CT and/or referral to CMHT re ?Frontal lobe dementia

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