Updated April 2014 Guide to the Enhanced Dementia Care Services

Transcription

1 Updated April 2014 Guide to the Enhanced Dementia Care Services Enhanced Dementia Care describes a model of care provided within a residential/day care unit, but with the capacity and skills to care for people with complex dementia care needs that cannot be adequately or safely met in other mainstream residential or day care services. The environments are tailored to the specific needs of people with dementia through providing additional staff training, support and in-reach on a regular and sustained basis from the specialist mental health service. Framework for Admission Criteria To access the enhanced provision the individual must have high level of needs in the following categories - and their needs are unable to be met in a mainstream residential or day care environment. This means that behaviour alone is the not the deciding factor as there are many stages to dementia and the need has to be overall complex in nature. behaviour cognition psychological and emotional and additional needs such as communication, mobility, nutrition and continence. These needs must have been clearly identified through a Multidisciplinary Assessment and evidenced. This might be a Mental Health Assessment (CPA) and a DICES Risk and Management Clinical Assessment process, the individual may also be eligible for Continuing Health Care. If the individual has other nursing needs these need to be adequately met within the provision, through the community nursing/mental health services or other health support from primary care services. Contractual Exclusion Criteria Anyone who has an acute mental health needs requiring intensive specialist inpatient treatment. Anyone who has an acute mental health needs requiring 24 hour on-going specialist mental health nursing care. Anyone who can be supported / managed at home or in mainstream services with in-reach from specialist services. People with acquired brain injury, or other neurological condition where not accompanied by a probable dementia process. People with a predominating mental health problem other than dementia, until that problem is stabilised. People with an acute confused state that has a physical cause. Any individual that is displaying behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self and/or others. The risks are so serious that they required access to an immediate and skilled response at all times for safe care.

2 NOTE - Please refer to the Mental Capacity Act 2005, the Mental Health Act 2007 and the Deprivation of Liberty Safeguards in every case where there is a question about a person s capacity. The principles should also be applied to all considerations of the individual s ability to make decisions and choices. Self funding placements - People who have been assessed as having the funds to contribute the full cost of their care, they are however only able to purchase a bed in enhanced long term. There are two routes; Admission through direct entry People can approach Cranwell directly without the involvement of Mental Health or Adult Social Care for admission to long term care if they wish to fund themselves. Cranwell must assure themselves that individuals meet the same criteria for needing enhanced care as ASC/MH. Admission through indirect entry - Anyone who is able to fund themselves but has been assessed through the adult social care process would not be excluded from receiving enhanced long term care and be placed within the block contract, however it is vital that all measures should be taken to ensure that they meet the enhanced provision framework and that a checklist is completed. Due to the way the beds are funded, it would mean that payment would be to the home direct, as the beds are block purchased. Fees vary depend on the care home. A contract variation would be drawn up to reduce the block placement for that bed for the duration of the stay. Use of emergency beds - There is access to 4 emergency/crisis beds. It is essential that these emergency beds are fluid in their use to ensure that there is capacity in the system. These beds are available within the Shared Care and Assessment unit, and NAViGO have the responsibility for gatekeeping the entrance to these beds and ensuring timely discharge. They can be used for further assessment to determine a forward plan for the individual. (See pathway for Community Emergency/ Crisis beds for further information). Essential life planning tool MyLife - For people diagnosed with dementia it is essential the care and support that they receive is focused around them, enabling them to be as independent as possible and remain in control of decisions that affect their life. The North East Lincolnshire Dementia Forum together with partner agencies and families have joined together to develop Person Centred Support Planning for people with dementia in North East Lincolnshire. MyLife is a series of planning tools that can be used to develop meaningful plans that outline the person and families wishes and it is the person and care-giver who know best. Any plan developed must ensure that the person along with their family is consulted at all times. This plan must be used for all people entering any type of enhanced care. All organisations should support the use of MyLife and encourage completion of the workbooks as early as possible to ensure it can be utilised during their care journey. Review of placements - Individuals using enhanced provision will be open to a Key Worker within an adult social care Complex Team and will be reviewed on a regular basis via an MDT to ensure the placement continues to meet their needs. (See process and framework for timescales). Review of enhanced provision framework - Development of this framework is an on-going piece of work and it is important that we update and amend it as necessary. It would useful if you could provide any relevant feedback in order to make sure it is a good support tool, and that it provides some measures to ensure that the enhanced beds are being used effectively. Please feedback to one of the following: jeanettelogan@nhs.net sue.ringrose@nhs.net katherine.eddington@nhs.net

3 ENHANCED DAY CARE Criteria People living at home with a diagnosis of dementia or significant cognitive impairment whose needs cannot be managed in mainstream day care services and require specialist day support Avoid the need for residential admission, short stay or hospital admissions and keep people in their own homes for as long as possible In a crisis, or to support short term assessment To enable the carer to have some respite from their role Provided at Cranwell Court, Cambridge Road, Grimsby The day service provides an enhanced social care model of high quality day care to meet the needs of people with complex dementia care needs. There are 12 places per day, Monday to Friday, with some flexibility for weekends and evenings on request. There are a range of opportunities designed to promote ordinary living through developing and maintaining links with existing community services. The adult social care CAF Assessment will capture the needs sufficiently for day care. The Advanced Care Practitioners authorising the day care placement will ensure the need is above mainstream position. The ethos of the day service is to support both the service user and the family enabling the person with dementia to remain as independent in their own home for as long as possible, whilst promoting a better understanding and awareness of dementia amongst families and the wider community by providing staff with a high level of skills to ensure their safety at all times. By engaging clients in the various activities the service aims to reduce anti-psychotic medication through the locally agreed Dementia Strategy. The service will offer a range of activities with the service user, and the staffing ratio will either be on a 1:1 basis with a key worker or within a group as appropriate to the individuals needs which will aim to enhance the quality of life. Some of the activities include:- Arts and crafts, cognitive stimulation therapy, computers, cookery, exercise and games, gardening (vegetable patch, sensory garden, potting shed), music and outings in the local community, individuals will also be able to access to the in-house hairdresser and chiropody. Staff will work with the individuals, their families, the case manager and the mental health team to identify outcomes and monitor progress in achieving these outcomes. (See review periods below - 6 weeks followed by 6 monthly). The unit provides a homely environment where the focus is on the feelings and dignity of each service user and that places high value on the quality of life, encouraging social interaction, and maintaining basic life skills whilst having fun!!

4 Referral Process and Framework for Dementia Enhanced Day Care Provision Pre - Admission Referral for Enhanced Unit through ASC Single Point of Acess A3 or if individual is known to complex team refer to Complex Case Focus ASC Case Manager - Assessment of need identifies the need for enhanced day support Integrated Case Manager (Dementia) - to provide advice and support if required. Contractual Exclusion Criteria: (Refer to exclusion criteria at pre-assessment stage) Focus ASC Case Manager - obtain approval from Advanced Care Practitioner Once approved Focus ASC Case Manager send the draft care plan to Cranwell Court day services Yes Enhanced day service to agree a pre-assessment date and the outcome of the assessment fed back to the Focus ASC Case Manager No Focus ASC Case Manager to look at alternative suitable provision to meet the assessed needs Agree on start date and confirm with all involved in the individuals care Support plan to be finalised Check if Essential Life Planning Tool (MyLife) is in place. If not commence development Focus ASC Case Manager/Mental Health/provider complete 6 week review with all those involved in the care to ensure an enhanced level of provision is appropriate and meets identified needs - followed by 6 monthly reviews Update Essential Life Planning Tool (MyLife) at each review Consider transfer to mainstream day care if appropriate

5 Enhanced Shared Care and Assessment including Emergency/Crisis access Provided at Cranwell Court, Cambridge Road, Grimsby Criteria The shared care and assessment facility can be used for one of the following reasons and the aim is to return the service user home as soon as possible. To enable the carer to have a break this may be planned or unplanned in an emergency. To enable a period of assessment - and observation to determine on-going need. Emergency/Crisis this might be an emergency that has arisen outside of office hours or due to an episode of poor mental health, or severe environmental situation or concerns regarding risk. There are 4 beds which provide bookable rotating respite care where care at home from the community services team is not practicable and this can provide palliative and end of life services when necessary. This is usually for a period of a few days or in some circumstances can be for up to 2 weeks. This is a chargeable service and the service user has to pay a contribution. The adult social care CAF assessment will capture the needs sufficiently for respite care. The Advanced Care Practitioners authorising the respite/short stay placement will ensure the need is above mainstream position. The approaches are founded upon enablement affording everyone the opportunity and means to achieve and maintain as much independence as possible. The shared care and assessment unit has the systems and staff in place to deal effectively and sensitively with short stay service users. Their work includes sharing the care and responsibilities with the informal carers and family, and provides an opportunity to enable participation in the activities of everyday living, through a range of meaningful activities on a flexible basis designed to improve their quality of life. Activities and routine will be based upon the persons needs and wishes rather than imposing a routine, and there are structured and therapeutic activity based interventions both in groups and on an individual basis. These might include e.g. art therapy, reality orientation, cognitive stimulation therapy, reminiscence and life story work. In addition, the quality of care will be assessed by an on-going cyclical process of observational techniques such as Dementia Care Mapping. A focus on Relationship Centred Care which includes family and friends in the day to day life and care plan of the individual as well as the possible involvement in any day care activities which they may also wish to be part of. This will focus on the individual s own personal interests and encourage them to take part in things they enjoy at the centre, or out in the community with support, enjoying activities and interests which are a part of their life when they return home. Emergency Access Criteria A crisis situation or change in circumstance that requires a place of safety for a short period To prevent a hospital admission There are 4 beds that can be specifically accessed in an emergency or crisis situation and provide care and assessment after significant life events where care at home is not immediately possible. These beds can be accessed through NAViGO by all agencies and are to be used for short term support - no longer than 6 weeks in total, however the referrer must review within that period and determine the ongoing needs after a multidisciplinary assessment, otherwise they will be responsible for on-going funding.

6 Referral Process and Framework for Dementia Respite care provision Shared Care and Assessment Bed Referral for respite through A3 or Complex Case Manager Pre Admission ASC Complex Case Manager - complete CAF Assessment or mental health worker. CPA Integrated Case Manager (Dementia) to provide advice and support if required ASC Complex Case Manager, Mental Health Integrated Case Manager (Dementia) to discuss Enhanced Care if required. ASC Complex Case Manager to obtain approval from the Advanced Care Practitioner with supporting evidence that enhanced care is required. Contractual Exclusion Criteria: (Refer to exclusion criteria at pre-assessment stage) Shared care Unit to agree a pre-assessment date with current provider and the outcome of the assessment to be fed back to the ASC Complex Case Manager. In a crisis situation this would require verbal discussion with follow up assessment. Yes NOTE: If respite is required in an emergency a pre-assessment may not take place No ASC Complex Case Manager to look at alternative suitable provision to meet the assessed needs Agree on respite dates or admission date for assessment period and confirm with all involved in the individuals care. Care Plan to be completed and financial contribution determined Check if Essential Life Planning Tool (MyLife) is in place. If not commence the development of this. RESPITE CARE ASC Complex Case Manager/Mental Health/Provider complete 6 week review from the first respite date with all those involved in the care to ensure an enhanced level of provision is appropriate and meets identified needs. Following this 6 monthly reviews for those using regular or rolling respite Update Essential Life Planning Tool (MyLife) at each review Reviews will then take place 6 monthly to ensure an enhanced level of provision is required

7 Community Emergency/Crisis bed management - Pathway FOR Organic and Functional Mental Health The CCG in partnership with NAViGO have commissioned two types of emergency/crisis beds to support people with organic and functional needs. These beds are within Cranwell Court, shared care and assessment unit for service users with dementia, and Sussex House Mental Health Care Home for service users with severe and enduring mental health problems that meet the frailty/fragility criteria. The ethos is that these beds will be used in the event of an Emergency/Crisis or unexpected deterioration to the individual s mental health needs. These short term placements will also provide support when needed in transition from an acute setting or, to avoid an inappropriate admission. There may be an unplanned or emergency situation with the carer of the person who has significant mental health needs and in this situation if a mainstream care home would not meet their needs, consideration should be given to an emergency bed in one of the available beds to support the carer role. In all cases every effort should be made to provide continued support in the person s home environment/care home in the first instance. Risks should be considered and where appropriate support should be sought from Primary Care, family members (as identified in contingency plans), home care services, or a range of intermediate tier services or mainstream care home. These emergency/crisis beds will only be used when there is clear evidence that the person poses too high a risk of further deterioration or that they pose a risk to themselves or others. It should be determined that without intervention the situation could lead to an admission to acute care and cannot be supported at home, without a high level of risk. They will not be used when there is an acute mental health need. The local facility available to meet this need is the Konar Suite at The Gardens. It is important to keep all links with Primary Care and ensure that the individuals GP and Primary Care Team are contacted as appropriate and kept informed of all crisis situations, placements and returns home. From April 2014 Gatekeeping responsibilities are changing as follows- - Admission to all emergency/crisis beds (Cranwell and Sussex) or shared care beds (Cranwell only) with the exception of planned respite care, will be proactively managed by the Home Treatment Team (HTT) NAViGO. This includes ensuring that crisis beds are used appropriately and for minimal timescales, through collaborative case working. - If Case Managers/Rapid Response/Home Team feel a bed is required to support an agreement will be determined by HTT. - Rapid Response referrals o Ideally the mental health need will have been identified in the triage assessment and a joint visit will have taken place with HTT. It may also be that the HTT identify a physical health need and they will therefore request a joint visit with Rapid Response. o Anyone inappropriately placed will be discussed with the placing practitioner within 48 hours, to start planning the move to a more suitable placement. Where possible all attempts should be made to return someone home as soon as possible. There is no cost to the service user throughout their stay in a crisis or shared care bed unless it is for planned rotating respite care. If it is identified that the person has long term adult social care needs, and there is no enablement potential then a referral should be made to the Focus Single Point of Access (SPA) for further triage. Response times from Focus will be dependent on the Triage outcome (determined through an electronic referral to Focus).

8 Emergency /Crisis beds There are 2 beds available at Sussex House. There are 4 beds available at Cranwell within the shared care/assessment unit. These beds are free at the point of access due to providing an intermediate care. - For any admission to a crisis bed it has been agreed that NAViGO can refer people with clearly identified Priority 1 needs that cannot be met through third sector/community services to Focus. The referral will take the form of an assessment, support plan and resource request. - Demand management is a primary function of Focus, all requests for resources will be scrutinised and returned to the referrer if appropriate. The Focus SPA and the Services4me database should be considered as a resource, and provide information for signposting to other services for all NAViGO staff. Focus staff are able to support with identifying alternative resources. Home Treatment Team availability - HTT is operational 7 days per week from 8am to 10pm. After 10pm all referrals will need to be directed via the SPA. If Rapid Response feel a mental health response is needed they will contact mental health via (MH)SPA and a Band 5 nurse from Konar (The Gardens inpatient unit) will accompany them to any urgent referrals. These practices and processes will need to be reviewed in July 2014 and amended as required. Referral routes will change when the multidisciplinary SPA is active.

9 Community Crisis / Bed Management Pathway for Organic and Functional Mental Health All referrals for Crisis/Emergency cases to be screened through NAViGO Mental Health SPA/Triage Deterioration in Mental Health (MH) e.g. agitation, aggression, psychosis, self-harm, low/high mood Refer to Home Treatment Team via MH Deterioration in Physical Health (PH) e.g. signs of infection, delirium, increase in symptoms of long term condition Refer to Rapid Response via A3 If Health Triage Assessment indicates physical need then joint visit with RR If Health Triage Assessment indicates MH need then joint visit with HTT Determine the risks/needs Maintain person at home Family / friends/ HTT/ Determine the risks/needs Maintain the person at home Family / friends/ IC@Home/ Admission to Emergency/Crisis Bed Inform Primary Care Primary Need Mental Health Identify appropriate bed for organic or functional need Primary Need Physical Health Identify appropriate bed for physical need Organic/ Cranwell Court Emergency / crisis Enablement Assessment Re-enablement Functional/ Sussex house Emergency /crisis Enablement Assessment Re-enablement Carer breakdown respite specific Generic care home Respite care (up to 7 days) Recovery and Recuperation Step up from Community/ Step down from DPoW/nursing input Beacon IC Re-enablement Rehab to return to own home As soon as possible after admission determine On-going Needs to Re-engage previous support /services / Commission new services / Assess for LTC

10 Crisis support for Residential Care Homes Care home provider to contact SPA Determine risks to To individual and others Timely response Eliminate Physical Health issues-rr/ Primary care Home treatment team (HTT)/ MH Crisis Team Commission Extra support to maintain current placement (In- reach support) Re-enablement -step up for fixed period Further assessment required Timely Discharge Placement in LTC Enhanced bed / Nursing Return to original placement Risk and Quality Panel funding approval required

11 Enhanced Residential Care Criteria (see enhanced checklist) To access enhanced provision the individual must have a set of high complex needs which may not necessarily just be around behaviour. They will usually fall into the following categories and their needs are unable to be met in a mainstream day care environment. cognition communication nutrition continence behaviour and psychological symptoms associated with dementia. Provided at: The Anchorage Rutland street Grimsby Grimsby Grange, Second Avenue, Grimsby Cranwell Court, Cambridge Road, Grimsby beds for individuals to privately fund) - 11 beds - 15 beds - 12 beds (+ 5 direct access These placements are available for long term care, but for some people the objectives of the service may be to enable them to return home or into mainstream service and will also provide palliative and end of life services when necessary. The enhanced residential care service provides a person-centred philosophy of care for all, with the key service focus on the daily involvement and participation in activities of everyday living for people with dementia, and uses methods of engaging with people based on their needs as an individual. The quality of care will be assessed by an ongoing cyclical process of observational techniques such as Dementia Care Mapping. This will be carried out on a regular basis and used to produce action plans for developing and improving service delivery, and for meeting individual needs. It is important that the ASC Complex Case Manager completes the Enhanced Care Checklist with the Mental Health Worker. Integrated Case Manager (Dementia) to provide advice and support if required and that they agree the Enhanced Care Framework is met. Following on from this the ASC Complex Case Manager will need to obtain approval from Risk and Quality Panel with supporting evidence that Enhanced Framework has been met and inform PACA. A focus on Relationship Centred Care which includes family and friends in the day to day life and care plan of the individual, as well as the possible involvement in meaningful activities which they may also wish to be part of. Focusing on the individual s own personal interests through a number of structured or therapeutic activity based interventions both in groups, and on an individual basis such as: therapeutic reminiscence, music & art therapy, memory re-orientation, singing practical, such as cooking or gardening entertainment, e.g. concerts, cinema enjoyment, such as art, crafts, exercise, walking The five direct bed accesses are available in addition to the block purchased beds, and access to these beds will be through arrangements with the individual, their family and Cranwell. The criteria for Enhanced Care must be met at all times. Individual contracts will be taken out between the care home and the individual. Indirect access to residential care beds through a ASC assessment should ensure that Finance and Contracting are informed to ensure that a contract variation is put in place for reduction to block contract, and an to workflow Systmone and Finance.

12 Referral Process and Framework for Dementia Enhanced Long Term Care Provision Pre - Admission Referral for Enhanced Unit through ASC Single Point of Access A3 or if individual is known to Complex Team refer to Complex Case Manager ASC Complex Case Manager to complete Enhanced Care Checklist with Mental Health Worker Integrated Case Manager (Dementia) to provide advice and support if required ASC Complex Case Manager, Mental Health Integrated Case Manager (Dementia) meeting to agree Enhanced Care Framework is met ASC Complex Case Manager to obtain approval from Risk and Quality Panel with supporting evidence that Enhanced Framework has been met and inform PACA Contractual Exclusion Criteria: (Refer to exclusion criteria at pre-assessment stage) Discuss and agree on choice of Enhanced Unit Enhanced Unit to agree a pre assessment date with current provider within 24 hrs. Yes No ASC Complex Case Manager to liaise with Mental Health to provide support Pre-admission Assessment completed by the Enhanced Unit. Outcome of the assessment fedback to the ASC Complex Case Manager Confirm decision to offer placement in conjunction with the Enhanced Unit and Adult Social Care Agree admission date based on professional judgement and personal circumstances Yes No Advise back to referrer Confirm responsibility for care plan Inform Finance and Contracting team for variation if person self-funding Check if Essential Life Planning Tool (MyLife) is in place - if not commence Individual admitted Yes ASC Complex Case Manager confirm paperwork Agree 2wk and 6wk review dates On Admission Within 2 weeks of admission ASC Complex Case Manager/Mental Health to complete 2 week review and arrange to complete the CHC checklist before the 6wk review. Forward CHC Checklist to CHC Team and await instruction regarding DST completion. Within 6 weeks of admission ASC Complex Case Manager/Mental Health complete 6 week review Update Essential Life Planning Tool (MyLife) Within 6 months of admission ASC Complex Case Manager/Mental Health - complete 6 month review. Update Essential Life Planning Tool (MyLife) - 6 monthly reviews to co-ordinate with mental health CPA reviews.