Improving services for people with dementia and

their carers in Tower Hamlets

Background

• 2009/10 and 2010/11, Tower Hamlets second worst in London for improvement performance in diagnosis rates of dementia.

• Numbers on primary care registers were low

• Dementia services were part of the general Community Mental Health Service for Older Adults

Challenges

• Fragmented services

• A battle to get an assessment

• Care staff reported little understanding of dementia

• Poor community engagement

Our Approach

• Dementia Strategy – what ‘good’ looks like.

• Project Board.

• Service users and carers at the centre

• Harness opportunities for integrated health and social care pathways

• Simple and streamlined

• Personalised

• Incorporate the Voluntary sector

• Joint commissioning approach – aligning spend and investment

• New integrated pathway

Our Partnerships

Our Pathway

Our System

REFERRAL

Diagnostic Memory Clinic

Older Adults Liaison Team

RLH

Community Mental Health Team

D

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t

i

a

A

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v

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s

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Dementia Care Team

LBTH

Adult Social Care

Intermediate Care Team

Wards Columbia Leadenhall The Green

Our New Services

• Diagnostic Memory Clinic

• Community Dementia Team

• Dementia Advisor service

• Dementia Liaison Service – Royal London Hospital

• Homecare services re-tendered specific requirements relating to users with Dementia Extra Care sheltered scheme for people with dementia

• Dementia Cafes

• Primary Care Liaison

• Liaison with CHS

• Care Home Liaison

Our Activity

84 117

89

190

335 300

050

100150200250300350400

Referrals to Memory Clinic

14235

17885

11315 9259

6868

0

5000

10000

15000

20000

Inpatient Dementia Assessment Occupied Bed Days (across ELFT)

479 519 643

0

200

400

600

800

2010/11 2011/12 2012/13projected

Spells coded as people with dementia at the Royal London

Hospital

249 302

449

671

0

200

400

600

800

2009/10 2010/11 2011/12 2012/13

MHCOP Psychiatric Liaison Referrals

0

50

100

150

200

250

300

DementiaAdviser Team

Outpatients Dementia CareTeam

Caseload 31/3/13 (total 725)

Medications commonly used to treat BC

•Anti-psychotics (typical/atypical) •Benzodiazepines*

•Anti-depressants

•Anti-convulsants

•Anti-dementia drugs

*sedative effect, ⬆confusion and risk of falls

Psychotropic medication to manage behaviour that challenges (BC) in care homes & extra-care sheltered accommodation in Tower Hamlets – May 2013 Plan

•request QOF registers from GP practices •East London Foundation Trust anti-psychotic audit tool to be introduced into CH & ECSS involving managers. •Staff training needs identified – (overview of dementia, BC, brain/memory, communication, personhood & activity) •Workshops in PAL & MCA

•Delivery of care staff training/workshops over 6-8 week rolling programme •Introduction of MDT input within care establishments

In progress •Joint working with primary care liaison practitioner & community virtual ward (CVW) to identify potential referrals

•Attendance at CVW practice meetings

•Staff (support) drop-in sessions for advice and information

•1:1 assessment & practical support in implementing non-pharmacological interventions

•Environmental modification •Protocol for management of BC

Referrals

Total 9

4=CH (BC) 5= ECSS (BC) Outcomes

2 (Neuro-psychiatric inventory) NPI-NH assessments

3 Pool Activity Level (PAL) assessment 3 advice & information 1 review

6 Extra-care sheltered schemes (ECSS)

202 residents approx. 20* with a diagnosis of dementia. 1 recently prescribed risperidone via GP

* underestimation

6 Care homes (CH)

333 residents approx. 167* with a diagnosis of dementia. 3 currently on Risperidone and 1 pending – all known to MHCOP

* underestimation

Most improved in

the country!

Percentage increase in diagnosis

in primary care 2011-12

This is the service

• MSNAP – Excellent

• PLAN – Awaiting results

• Local Government Chronicle Award for Health and Social Care Partnership 2012

• ELFT – Runner up Team of the Year 2012

• March 2012 – Visit from The Director General for Social Care , DOH

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| Waltham Forest, East London and the City 13 13

Integrated care teams: End-state vision Network Locality Practice

3

4 1

Tower Hamlets will have 4 locality integrated

community health teams, aligned to 8 primary care networks

Network level

Network 3

Network 4

Network 5

Network 6

Network 2

Network 1

Network 7

Network 8

CCG level

Social care

specialist

Mental health

specialist

Acute

specialist

Disease specific

specialist teams

Locality level

ICHT 1

▪ Community

Matrons

▪ Senior AHP

▪ Nurses

▪ Social workers

▪ Other AHPs

▪ Case managers

▪ Care navigators

▪ Community

Mental Health

▪ Hybrid health/

social workers

ICHT 2

ICHT 3

ICHT 4

Clearly defined interface

between networks and ICHT.

Single case manager / care

navigator accountable for

each patient (across primary

and community care settings)

Team includes dedicated case managers for Very

High Risk patients (70-100 patients each), and care

navigation function for High Risk patients

(dedicated or part-time role, TBD)

Case conferences at network

level (GP, practice nurse, HCA,

network manager, network

administrator, case

manager/care navigator, other

relevant staff from ICHT / CCG

level specialists)

▪ Community

Matrons

▪ Senior AHP

▪ Nurses

▪ Social workers

▪ Other AHPs

▪ Case managers

▪ Care navigators

▪ Community

Mental Health

▪ Hybrid health/

social workers

▪ Community

Matrons

▪ Senior AHP

▪ Nurses

▪ Social workers

▪ Other AHPs

▪ Case managers

▪ Care navigators

▪ Community

Mental Health

▪ Hybrid health/

social workers

▪ Community

Matrons

▪ Senior AHP

▪ Nurses

▪ Social workers

▪ Other AHPs

▪ Case managers

▪ Care navigators

▪ Community

Mental Health

▪ Hybrid health/

social workers

CARE COORDINATION: FUTURE

From the service users and carers perspective…Next steps …

• A one stop shop… Integrated health and social care assessment and care planning

• A contact person who understands dementia for as long as needed

• Advanced care planning

• Peer support and therapeutic groups

• Personalised care and support

• Assistive technology

• People participation

• BME outreach…

Some recent feedback “Very thorough discussion regarding the assessment

process and the diagnosis result was relayed in the

nicest fashion.”

Service user, Memory Service National

Accreditation Process

“Good continuity and letters. Excellent nurses. I have

been called by their doctors about patients and also to

tell me changes in care. They seem very good. They do

home visits - doctors seem motivated and caring.”

GP, Memory Service National Accreditation Process

“It was good to get out of the house. Thank you very

much for putting a smile on our faces.”

Service user

“It brought Jane to life: it was a lifesaver.”

Service user