Waitemata DHB Cognitive Impairment Clinical Pathway

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1 Waitemata DHB Cognitive Impairment Clinical Pathway Delivering National Dementia Care Framework Karen Holland, Project Manager - Phone:

2 Element 2: assessment & diagnosis Waitemata DHB Cognitive Impairment Clinical Pathway is designed to provide: Timely access to skilled assessment Earlier diagnosis of dementia Earlier connection for the person, their carer / family / whanau with appropriate education and support The opportunity for the person to live well with dementia. 2

3 How Is Waitemata DHB Developing Its Dementia Clinical Pathway? Waitemata DHB Specialised Services Older Adults (SSOA) Clinical Reference Group: Convened November 2012, meets monthly First task - develop Waitemata DHB Cognitive Impairment Clinical Pathway (based on NICE Guidelines, NZ Dementia Care Pathway Framework, Northern Region Dementia Services Guide, Read Only access granted to Canterbury DHB Cognitive Impairment Pathway) Pathway pilot Pilot evaluated to inform rollout Roll out across the DHBs 300 general practices over a 2 year timeframe 2014/2015 & 2015/

4 Who Is On The SSOA Clinical Reference Group? Core membership: - PHO Clinical Directors (Procare & Waitemata PHO) - Clinical Directors Geriatric Medicine & Psychiatry of Old Age - Director Community Health Nursing - Head of Dept Allied Health Co-opted membership dementia specific includes: - Alzheimers Auckland - Memory Clinic Clinical Leader - Neuropsychologist - Dementia Nurse Specialist - Gerontology Nurse Specialists (GNS) - Mental Health Services Older Adults (MHSOA) Team 4

5 Who Is On The SSOA Clinical Reference Group? (Cont.) Representatives - PHO Nurses Leaders - Occupational Therapist, Dementia Specialty Regional DHB Dementia Project Clinical Leaders & NDSA Leads Invited to meetings since March

6 What is the focus of the Waitemata DHB Cognitive Impairment Pathway? Similar to Canterbury Pathway Aim to have mild cognitive impairment (MCI) and non-complex dementia diagnosed and managed by general practices Structured education & mentoring for general practice General practice connects person /carer / family / whanau with Alzheimers Auckland for education & support Clearer and more timely referral pathway to Waitemata DHB secondary / tertiary services for uncertain diagnosis, complex dementia, or significant BPSD. 6

7 What general practice steps are on the pathway? GP 1 st visit includes: - History taking to exclude other conditions (e.g. delirium, Parkinsons etc) & to support diagnosis - Mini Cog screen by GP - Request for carer/family to complete IQ Code before the GP 2 nd visit - Request for blood & urine tests - referral for MoCA by Practice Nurse or Alzheimers Auckland - based on pathway criteria: referral to OT for functional assessment - based on pathway criteria: GP can request CT Head (Waitemata DHB Radiology will accept these GP referrals based on the same criteria as Canterbury Pathway) 7

8 What general practice steps are on the pathway? (Cont.) If diagnosis is non-complex dementia GP 2 nd visit includes: - explanation of above results - discuss commencement of Dementia specific medication - refer to Alzheimers Auckland for education & support programme - refer to NASC for package of care assessment 8

9 What general practice steps are on the pathway? (Cont.) Soon after GP 2 nd Visit a Care Planning Meeting including: Patient / Carer / Family / Whanau; GP; Alzheimers Auckland; NASC; OT (if involved) to agree Care Plan inclusive of: - Identify Care-Plan Co-ordinator ; likely that Alzheimers Auckland best positioned for this role - NZTA on road driving safety assessment - EPOA (enduring powers of attorney) - WINZ for disability allowance assessment - Advanced Care Plan (determine who & when discussions will happen) - Set next Care Plan review date. 9

10 What general practice steps are on the pathway? (Cont.) If diagnosis is mild cognitive impairment (MCI): Now that the non complex dementia section of the clinical pathway is almost confirmed by the SSOA Clinical Reference Group the MCI section will have detailed discussion to confirm content 10

11 What general practice steps are on the pathway? (Cont.) If diagnosis is uncertain, complex dementia, or significant BPSD referral to secondary care / tertiary care services Still to be confirmed on the pathway the referral criteria to and management within: - Gerontology Nurse Specialist (GNS), - Geriatrician Services, - Memory Service, - Mental Health Services Older Adults (MHSOA). 11

12 What enablers will there be to guide general practice use of the pathway? Recent purchase by Northern Region (4 DHBs) of IT Enabler for Clinical Pathways (all pathways) - will be embedded in DHB & PHO Patient Management Systems - will provide decision support functionality - will interface with both the ereferrals & e Shared Care - will require a Regional Cognitive Impairment Clinical Pathway 12

13 What enablers will there be to guide general practice now? Waitemata PHO has separate contract with Health Workforce NZ (HWKNZ) to develop a Dementia IT Decision Support Tool for use inside Medtech Practice Management System (PMS) Waitemata DHB SSOA Clinical Reference Group is providing the clinical decision making for the Waitemata PHO Dementia IT Decision Support Tool Waitemata PHO testing the Dementia IT Decision Support Tool with 2 of their general practices Pilot of Waitemata DHB Cognitive Impairment Clinical Pathway will include piloting the Dementia IT Decision Support Tool Future implementation of the Northern Region Clinical Pathways IT Enabler will require determination of the fit of the Waitemata PHO developed IT Dementia Decision Support Tool 13

14 Who will pilot Waitemata DHB Cognitive Impairment Clinical Pathway? From : 12 general practices being 6 per PHO (Waitemata PHO practices will be 6 practices separate from the IT Dementia Decision Support Tool testing practices) Education & mentoring package for these 12 general practices Each practice will case-find 5 patients = 60 patients Secondary & Tertiary services will run 2 systems retain current model for non pilot patients and test new referral pathway for pilot patients so this can be evaluated to inform required restructure. 14

15 How will we know if the Waitemata DHB Cognitive Impairment Pathway can improve dementia care? Waitemata DHB SSOA Clinical Reference Group (i.e. primary & secondary care clinical leaders jointly) will determine if any changes need to be made to the clinical pathway during the pilot period Auckland University Evaluation of the pilot. 15

16 Waitemata DHB Cognitive Impairment Clinical Pathway Intent Waitemata DHB is working with primary & community care to: Improve services for people with cognitive impairment, particularly for people with diagnosed dementia Integrate cognitive impairment services to support people to live safely at home Deliver the intent and content of the National Dementia Care Framework. 16

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