1. Reducing hospital admissions Improving care for people with dementia

2. QIPP Principles Whole health and social care economies Teams include patients, social care, community services, AHP’s, general practices and secondary care clinicians 20% reduction in unscheduled admissions 25% reduction in length of stay Reduction in readmission within 30 days

3. Cornwall background The prevalence of dementia increases markedly with age and in the UK it is estimated that some 750,000 people have dementia. In Cornwall public health epidemiological data suggests anticipated prevalence of dementia is 8536 however only 3752 of people with dementia recorded on GP QOF registers (March -11).

4. Care homes admissions RCHT Total number of admissions 2009: 1654 Total number of admissions 2010: 1856 999 calls Jan 2011 227

5. More than 4 campaign Identify reasons for admissions, Training needs analysis Implement training Join up systems and intelligence, Enhance and improve patient care.

6. Impact on clinical quality Joined up intelligence Educated and supported workforce Develop what to do if flow chart for common conditions. Awareness of disease pathology When to call the GP Simple nursing care procedures Improved patient care in the right place at the right time Safe and appropriate care to meet individual needs Reduction inappropriate prescribing Reduction anti psychotics Reduction in falls Tele-health implementation Better end of life care Better pain control and assessment. Access to specialist clinicians and services :

7. More than 4 Nursing care home admissions audit Monthly Case note review more than 4 admissions Data collection End of life dementia pilot Care home survey Amp Tele-health

9. Care home questionnaire The rationale for a countywide care home questionnaire and a review of services, was to report ‘thematically’ on the effectiveness of the current services, potential gaps and suggest improvements from the care home staff perspective. The review made use of 30-minute telephone interviews with care home professionals (n=27) from high and low admitting care homes.

10. Common themes Low admitting care homes: 1-2 GP Practice per home Regular ward rounds and review (many on a weekly basis). Combination of RMN and RGN nursing staff District nurse in-reach

11. Support to care homes can be split into three main areas Medical and pharmacist support Community service support Training and education

12. Support (continued) Service directory for care homes 1-2 (max) GP practice per care home End of life pathway for dementia Dementia training for some GPs especially medication management District nurse and /or Community matron input and support Someone to call just to talk things through rather than call 999 Serco first, Responsive community mental health teams.

13. Care home audit 2009

14. Aim Audit : To identify the numbers of patients admitted from nursing homes with a view to: 1. Identifying the appropriateness of admission i.e. those requiring acute care (whether there is an alternative to admission to hospital). 2. Determining a care pathway to prevent unnecessary admission 3. Facilitating the patient illness journey in the best setting for the individual. 4. Considering the potential cost implications of inappropriate acute admissions of people with dementia

15. Methodology A case note audit of patients with known diagnosis of dementia admitted into an acute district hospital (Royal Cornwall Hospital) from registered nursing care homes in Cornwall. The patient cohort identified using monthly admission figures provided by the NHSCIO Review of medical records in conjunction with a written proforma.

16. Key areas for scrutiny included: 1. Source of referral i.e. A&E or via GP 2. Involvement of GP prior to admission 3. Hour of admission 4. Reason for admission / Diagnoses 5. Length of stay 6. Place of discharge (final outcome) 7. Alternative treatment options 8. Cost implications around end of life care and admissions

17. Results n221 case notes were reviewed The total number of admissions from nursing homes to Royal Cornwall Hospital during 2009 was 534. Only those with a known diagnosis of dementia were included. Exclusions included those attending Accident and Emergency Dept. but not admitted, and those attending for elective surgery. The median age for participants was 81 (range 54- 104).

18. Source of Referrals The number of patients referred by GP was 90 (41%), 131 (59%) were admitted via emergency 999 service;

19. Break down of 999 emergency admissions

20. 999 admissions 131 were admitted via 999 paramedic/ambulance services. 28 were appropriate (103 alternative options to hospital admission could have been offered. 97 admitted during standard working hours In total study (n221); 71 were admitted for end of life care (palliative) of whom 59 (83%) were admitted via 999 services and 19 patients (27%) were admitted out of standard working hours.

21. GP Involvement 54% required acute care.

22. Reasons for Admission to RCH Medical ConditionsNumber of patients (n221) Percentage % Infection LRTI UTI Other(ulcers/gangrene, meningitis) 39 23 9 7 17.6 Falls Fracture No fracture 30 16 14 13.6 Cardiac (MI,ACS,AF,CCF)167.3 Stroke146.3 Breathlessness and fatigue115.2

23. The majority of admissions were via medicine (n195 ; 90%), the rest were a mixture of orthopaedics (n11 ; 4%) and surgery (n15 ;6%). 59% (n130) patients who were admitted to RCHT during this 11 month period did not require acute care –98 (44%) admitted via 999 services. 8 (7%) required step up care and 71 (57%) were palliative, therefore there were 41 other individuals who may have received care at home thus avoiding admission 28 of whom were 999 admissions.

24. Final Outcome (Discharge or Death). 70% of patients were discharged back to their original nursing home, 4% were discharged to a step up care and 26% died in hospital.

25. Outcomes and Alternative Options Alternative treatment option Number of patients Antibiotics25 Intravenous fluids4 Bowel /bladder care4 Pain management7 Stroke/TIA (in severe dementia) – no intervention 4 Falls prevention10 End of Life care plan67 Step up – place direct from community 9 Total130 (59%)

26. End of Life Care In relation to those patients with advanced terminal phase dementia, 71 (32%) were palliative. Died in Hospital 58 (81 % of EoL subgroup) Transferred back to Home13 (19% of EoL subgroup )

27. EoL Costing ( based of non elective national tariff) Total £ 143485 (over 11 months) (Mean £ 124504) Mean cost per person admitted for Eol care £ 1486.24 ( £ 2020.92 +cc). The above is based on PbR Tariff for 2010-11 – these figures were used to help quantify costing in real time.

28. Implications for Practice and Recommendations Identifying End stage Dementia There is a clear need to identify those with advanced terminal dementia within their care setting and instigate plans for care that are anticipatory, respectful of best interest and advocacy, appropriate to meet the needs of the individual client.

29. End of Life Planning End of life planning / care pathways prevent unnecessary admission to acute care and enhance the delivery of palliative care for this client group in the care home setting.

30. End stage dementia Pilot What is End stage dementia End of life dementia pilot Education to staff and carers Pathway Best Interest document (front notes flag to Oohrs) Allow a natural death

31. Response so far Over 300 patients 7 x care homes All GPs signed up Out of hours 999 Relatives feedback positive People dying in own care home and less admissions before death

32. ?