Norfolk Dementia Care Pathway. Zena Aldridge; Lesley-Ann Knox; Hilda Hayo

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1 Norfolk Dementia Care Pathway Zena Aldridge; Lesley-Ann Knox; Hilda Hayo

2 Need? Growing numbers of people with dementia. Majority live in their own homes. Family members providing care estimated to save the nation 17.4 billion. High multiple health and social care needs. Patchy services.

3 A potted history of Admiral Nursing Family experience. Secondary mental health. Specialist dementia nurses. Family focused.

4 What does an Admiral Nurse do? Family & relationship centred approach. Work in partnership. Specialist assessment & evidence based intervention. Promote and implement best practice. Provide supportive education. Provide biopsychosocial support for the carer and person living with dementia. Liaison with other professionals and organisations. Work in consultancy and supervisory role.

5 Structure

6 Setting the scene Currently estimated to be 16,400 people with dementia in Norfolk. Figures are expected to rise to 25,512 by ref: Public Health 2014

7 Pilot Area and Resources Seven GP Practices in mid-norfolk. Three Admiral Nurses. Norfolk and Suffolk Foundation Trust West+ area.

8 Themes identified for the evaluation Improved well being Improved diagnosis rates Caseload management Reduced admissions Improved outcomes for end of life Value for money

9 Evaluation Methodology Carer telephone interviews = 37 participants Peer Questionnaires issued to professionals = 100 issued with a 28% return rate Data collection from Admiral Nurse cases = Data collated from 112 of 230 cases

10 Improved wellbeing 75% of carers interviewed made reference to low mood/ depression and anxiety symptoms as well as an inability to cope. They are the only service for me. All other professionals help my husband. She made life easier. I rely on her quite a bit. She gives sound advice. She s saved my mental health.

11 Improved diagnosis rates 12 of 112 cases (>10%) have been supported to seek a diagnosis. Improved identification of cases via the Professional Liaison role of the Admiral Nurse.

12 Caseload Management 94% of professionals said that contact with the Admiral Nurse Service had improved their confidence in dealing with dementia patients and their carers. Professionals reporting reduced contact time: 60% GPs 16% Nurses 100% Social Workers The Admiral Nurse Service is the most valuable, helpful and reliable service that I and the carers I see, have been able to access. (GP quote)

13 Reduced Admissions (mental health) 8 admissions avoided. Mrs S has impulsive behaviour leading to suicidal thoughts which she has acted on in the past. Her husband struggled to manage this and was supported to recognise risk indicators and minimise risk to prevent crisis occurring that could lead to mental health admissions.

14 Reduced Admissions-acute 26 cases were likely to have resulted in admission without input of an Admiral Nurse. Early recognition of infection/delirium reduced likelihood of admission. By identifying patients who were coming to End Of Life they were enabled to go onto the Gold Standards Framework.

15 Reduced admissions to long term care 29 of 112 cases were delayed or avoided. 2 to 38 weeks of residential/nursing care savings. Achieved by avoiding emergency admissions and preventing permanent admissions.

16 Improved outcomes at End of Life a lifesaver I can t praise her [Admiral Nurse] enough. I can t discuss grieving with my family and she [Admiral Nurse] provides space and time just for me and my thoughts. If it wasn t for the Admiral Nurses, Steve would not have had the perfect death. They knew what to do for him, me and the whole family. We wanted Steve to die at home, not in a hospital where he didn t belong.

17 Unanticipated Outcomes 8 safeguarding referrals avoided. Reduction in referrals to the Dementia Intensive Support Team. Access to preferred place of care. Advanced care planning. Participation in operational and strategic Boards. Increasing use of support from national Admiral Nurse DIRECT phone line.

18 Value for money Direct savings of 443,593+: 63,074 Acute. 8 mental health hospital admissions (tariff not available). 20,760 Continuing Health Care. 16,992 (approx) IAPT/counselling. 342,767care homes.

19 Indirect savings 45 people with dementia reported improved well-being. 75% carers reported low mood, depression and anxiety prior to support. 3 people supported at end of life.

20 Evaluation conclusion There has been a positive impact on the 7 key areas investigated. Service outcomes: Carers It s a lifeline Professionals excellent and vital Savings direct and indirect

21 Future proposals Pathway. Partners. Roles within the Pathway.

22 Dementia and end of life care: collaborative working By Lesley-Ann Knox RN BSc Care Home Facilitator

23 Care Home Facilitator Role purpose To work collaboratively with care home managers; To support and educate care home staff; To increase the number of patients dying in their preferred place of death; and To avoid unnecessary hospital admissions.

24 Care Home Facilitator Role teaching plan Based on National End of Life Care Pathway; Covers: Principles of Gold Standards Framework/6 Steps; Advance Care Planning; Care of the dying resident; Fulfils the requirements of the EOLC Strategy Quality Markers. Is in keeping with the principles of good holistic palliative care; and Introduces staff to good communication skills.

25 Care Home Facilitator Role working collaboratively Age UK (Admiral Nurses) Learning Disabilities team; Community Matrons; Safeguarding; Community teams; Specialist Nurses; Discharge Co-ordinators; GPs.

26 End of life care for people with dementia workshops For NCH&C staff and other providers Registered nurses, therapists, health care assistants, social workers, doctors, volunteers, care home staff, learning disability carers etc. Weaving the two worlds of dementia and end of life care together encouraging participants to deliver care in a timely and seamless way.

27 Workshops include: Is dementia a life-limiting illness? What is palliative care? What is dementia? Types of dementia; Identifying that a person may be in the last year of life; Communication; Advance care planning; Carers needs; Loss, grief and bereavement; Symptom control; Five priorities for care of the dying person; Case Studies.

28 Feedback Will introduce Pabulum Blue Book to my work place (RN) I now have more understanding about communicating with someone with dementia (OT) There are different types of dementia (HCA) Need for a pain assessment tool that looks for behaviours (Care Home HCA) The benefits of identifying someone who might be in last year of life (RN) The timely completion of important documents such as advance care planning/this is Me (DN). Useful information about swallowing it would be good to use aspects of this for GP training. It is always good to have an update on end of life care. (GP)

29 Staged approach Mental Health Trust EOLC pathway for people with dementia Challenging practice

30 Finally.. Admiral nurses/palliative Care teams share ideas, give peer support, and share best practice: use of advance care plans And Out of hours handover forms Shadowing Sharing expertise in care homes

31 Finally.. Admiral nurses/palliative Care teams share ideas, give peer support, and share best practice: use of advance care plans And Out of hours handover forms Shadowing Sharing expertise in care homes

32 Thank you for listening Admiral Nursing DIRECT: or

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