Collaborative working in Dementia Care:Multiple disciplines, multiple teams, just one patient

Dr Adam GordonConsultant and Honorary Associate Professor

Nottingham University Hospitals NHS Trust

Honorary Secretary – British Geriatrics Society

Email: adam.gordon@nottingham.ac.uk

adamgordon1978

INTERMEDIATE CARE

COMMUNITY MATRON

FALLS TEAMS

COMMUNITYGERIATRICIAN

CARE HOMES

COMMUNITY STROKE REHAB

COMMUNITY MENTAL HEALTH

SOCIAL WORK

GENERAL PRACTITIONER

REABLEMENT TEAMS

ACUTE HOSPITAL TEAMS

RAPID ACCESS LIAISONPSYCHIATRY

HOME CARE PROVIDERS

Secondary Care

Primary Care Social Care

Comorbidity of 10 common conditions among UK primary care patients.

Guthrie B et al. BMJ 2012;345:bmj.e6341

©2012 by British Medical Journal Publishing Group

Body functionsand structures Activity Participation

Personal factors

Environment

Body functionsand structures Activity Participation

Personal factors

Environment

Goal settingEncouragementBehaviour change

Aids & appliancesAdaptations

Co-operationAssistanceLegalSocietal

Rehabilitation therapiesTreatment of “barriers”Information givingSkills training

Staff Interviews in Care Staff Interviews in Care Homes (STICH) StudyHomes (STICH) Study

• 7 care home managers7 care home managers• 2 care home nurses2 care home nurses• 9 care home care assistants9 care home care assistants• 6 GPs6 GPs• 3 dementia outreach nurses3 dementia outreach nurses• 2 district nurses2 district nurses• 2 advance nurse practitioners2 advance nurse practitioners• 1 OT1 OT

Common problemsCommon problems

Older people are very complicated.Older people are very complicated. Trajectories are difficult to predict.Trajectories are difficult to predict. Don’t have the training.Don’t have the training. Resources are tight.Resources are tight. Regulation is always present.Regulation is always present. Roles and responsibilities aren’t Roles and responsibilities aren’t

clear.clear. Communication is a problem.Communication is a problem.

Important observationImportant observation

•Care home managers are pivotal.Care home managers are pivotal.

•Relationships between GPs and care Relationships between GPs and care home managers are pivotal.home managers are pivotal.

Identified responsesIdentified responses

Regulate (stick)Regulate (stick)

Remunerate (carrot)Remunerate (carrot)

Parachute in troopsParachute in troops

The social movement model.The social movement model.

Mechanistic solutions – Mechanistic solutions – the “LES”the “LES”

Comprehensive assessment at the point of Comprehensive assessment at the point of admission.admission.

Regular contact with home (at least two Regular contact with home (at least two weekly).weekly).

Regular review of resident (at least 6 Regular review of resident (at least 6 monthly).monthly).

1:1 relationships GP:care home.1:1 relationships GP:care home.

Necessary but not Necessary but not sufficientsufficient

CGA

What is the evidence base for Comprehensive Geriatric Assessment (CGA)?TypeType MortalityMortality Living at Living at

homehomeReadmissiReadmissionon

Physical Physical functionfunction

Cognitive Cognitive functionfunction

InstitutioInstitutionalnal

0.780.78

(0.62-(0.62-0.97)0.97)

1.191.19

(1.01-(1.01-1.39)1.39)

0.850.85

(0.70-(0.70-1.03) 1.03)

1.221.22

(0.84-(0.84-1.78)1.78)

1.791.79

(0.73-(0.73-1.46)1.46)

Non-Non-institutioinstitutionalnal

0.910.91

(0.77-(0.77-1.07)1.07)

1.261.26

(1.10-(1.10-1.44)1.44)

0.890.89

(0.78-(0.78-1.01)1.01)

0.990.99

(0.77-(0.77-1.27)1.27)

1.031.03

(0.73-(0.73-1.46) 1.46)

CombineCombinedd

0.860.86

(0.75-(0.75-0.98)0.98)

1.261.26

(1.10-(1.10-1.44)1.44)

0.880.88

(0.79-(0.79-0.98)0.98)

1.061.06

(0.86-(0.86-1.30)1.30)

1.411.41

(1.12-(1.12-1.77)1.77)

Stuck AE, Siu AL, Wieland GD, Rubenstein LZ, Adams J: Comprehensive geriatric assessment: a meta-analysis of

controlled trials. Lancet 1993, 342:1032–1036.

• Patients don’t recognise “health”, “social”, “primary”, “secondary”, “physical”, “mental” care.

• They just recognise care.

• Patient’s lives aren’t driven by diagnoses, they’re driven by problems.

• More holistic approaches to healthcare are required.

• CGA is a holistic approach – but still healthcare dominant.

• Relationship-centred care, with patient and carers in the middle has to be the ultimate goal.