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hereweare.org.uk
Financial Management Commissioned in 2012 and operational delivery commenced in 2013
Purpose: •Improve the DDR – recorded at 36.5% - estimated prevalence of 3K •Early intervention •Improvement of timely diagnosis - 10 week target Referral to diagnosis •Improve quality of life - Post diagnosis support service for patients and carers for 1 year •Reduce stigma surrounding dementia.
Model: Patients: 60 years old and over Clinical pathway : Community Service, CPN lead service with consultant and GP support Support pathway: Dementia Advisors and Carer Support Worker How did it perform?
•Significant improvement in DDR •Not compliant with access targets or referral to diagnosis •Lack of visibility and evidence on quality of support service or quality of life
What happened in July 2015? • Change in commissioners and service management and Remedial Action Plan from CCG to
address patient journey times.
MAS 2013 to 2015
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Financial Management
Patient Journey Times May 2015 – 20 weeks April 2016 – 10 Weeks (patient choice included) / 6 weeks (patient choice excluded)
How did it perform?
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Financial Management Action Group Dec 2015: Purpose: • To understand how the current service is organised and delivered • The impact this has on the outcomes and experience for citizens / patients and their families Approach:
• MDT plus commissioner involvement • Case studies mapped from referral to discharge • Live observation of service interactions with patients and carers –face to face clinical and
support and telephone phone appointments + focus groups We found that: • There is often a significant gap between the services we currently provide and the support
people are asking for.
• What matters to our citizens is lost, not heard or responded to.
Questioning the KPI?
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Financial Management Referral & Demand • Presumed dementia and high function pts referred • People often referred in crisis or when family can no longer support • The expectations of what we can offer are unclear Assessment/ Diagnosis / Treatment: • Assessment & Diagnosis is not always timely • Service unable to flex to meets the needs • Assessment is not harmless • Diagnosis is life changing • There is minimal support offered to adjust • What matters to our patients is not reviewed until care planning post diagnosis • Unmet need of patient referred if dementia diagnosis not made Support: • We provide good information but no one person holds ownership of the person • Advice and guidance is not sufficient and there is gaps between commissioned services • Services are not joined up across the city and hard to navigate and access
Learning
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Financial Management
Of the patients reviewed 70% were requesting support and
diagnosis was not their priority
New Service purpose:
Help me and my loved ones to get the support and information we need to
live our lives well.
Learning
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Financial Management Investment in additional support staff to increase the support service, improve continuity of care and work in a proactive way to improve patient experience and reduce the pathway to dependency. Support at the point of referral. Service assigned a named Memory Support Worker assigned for the entirety of their time with the service to: Improve continuity of care. Friendly face for advice and guidance and support planning. Improve citizens experience of the service and the clinical pathway Navigator of the service and the wider healthcare system. • First Contact Calls 1. What matters most conversations with patients and carers/NOK 2. Patient & NOK set the pace 3. Support needs understood 4. Support network understood 5. Consent to share information and with who 6. Explaining how the service can benefit them 7. Barriers to engagement reviewed & understood with a view to removing them 8. Suitability for MAS
MSW identify support needs and start delivering upon them!
How the service responded
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Financial Management Enhanced Support Bridging the gap between MAS and crisis services to work with our most vulnerable patients to help crisis avoidance. David is a 68 year old man who lives alone, with no family and a history of alcohol abuse and homelessness. David has been diagnosed with Parkinson’s dementia and has increasing care and support needs but does not want anyone coming into his home.
Enhanced Support Case Study
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Financial Management
Outcomes MSW visited David 10 times over the 2 years that he was in the service and were able to respond quickly when he was in need • David is now receiving a 3 x a day package of care for
help with personal care, taking medication and meal preparation.
• With help in taking his Parkinson's medication, David feels more mobile and ‘clear headed’ meaning that he can continue to go out of the house and do things he enjoys
• David is now receiving all of the benefits that he is entitled to which can help cover his care costs
• With the package of care, someone will see David each day so he should not reach crisis point again MSWs will visit David one more time and then he will be discharged from the service.
Enhanced Support Case Study David’s Outcomes
Principles met • We pay attention to your emotional and
psychological needs
• We will hold you until we have found or helped you to find solutions to what matters to you
• You set the pace and you will always know where you are in our service
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Financial Management Post Diagnostic Support
Post Diagnostic Support Care Plan appointment delivered at Alzheimer’s Society Brighton base. Structured support – structured support implemented post diagnosis throughout the year (3, 6, 9 and 11 month).
Access to Cognitive Stimulation and Living Well With Dementia
Access to locally commissioned psychosocial groups Peer Support groups - monthly groups delivered for both dementia and MCI patients and their carers / NOK to : • aiding a reduction in social isolation • Sharing experiences • Make new connections and building friendships • Inviting speakers from community groups and psychosocial groups across the city • Tips on managing memory problems • Helps service manage risk / monitor decline etc
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Operational reporting summary Patient Feedback July 2017 –Dec 17 Did the service help you understand your diagnosis: 97% Do you feel our staff treated you with compassion, respect and dignity : 100% verbatim patient feedback: “I don’t feel alone”. “In my experience I cant find they need to improve anything”
“It’s so helpful…having someone who you build a relationship with; who can come to your door” ‘It’s been so helpful having someone who knows the system’ ‘The ‘beauty’ of these meetings is learning about other things that are going on…sharing experiences.’ “We’ve got everything to gain and nothing to lose (by attending the group)”
“MSW was very helpful, she gave us lots of useful information about Alzheimer's and groups to join. She was very friendly and easy to talk to.” “Impressed with co-ordination between, gp, rapid assessment unit, social services and memory assessment service…..” “Good to know that there is support available for both of us.” “Every member of staff has been most helpful - polite - understanding, helped my husband to understand more about my illness. From first contact things moved very quickly. “I (husband) have filled in this form in as my wife cannot remember seeing you but it has helped me understand and I thank you for it..”
Patient Feedback for Service
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Financial Management Benefit to patients and service. • Year 5 average quality of life measure reported that 83% of respondents reported a maintenance
or improvement in quality of life.
• High patient satisfaction.
• Praise from CQC – patients at the heart of the service
• Here won 2 national awards for our redesign.
• Patient and carers more connected and integrated with the wider health and social care system including community support services
• Helps improve patient journey times
• Better use of capacity –appointment utilisation across the service and home visit appointments • Less urgent onward referral at assessment & reduction in inappropriate assessments
• Better at safeguarding & risk management
• Proactive working to help crisis avoidance – probable saving on wider system
• A more rewarding service to work in.
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Financial Management Given all the learning we feel it’s vital that : • Our citizens can set the pace of their journey and service to respond appropriately • Ensure data capture of patient choice. • Support at the point of referral. • MSW to support throughout their time with the service. • Patients being at the heart of decision making regarding their care.
Access Targets • Working with support at the point of referral what does this mean for access targets?
• Is this a case for the defense regarding access targets?
Summary
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Financial Management Patient Journey Times for MAS
July 2018 : Referral to Diagnosis : 6 weeks (pt choice excluded) and 13 weeks included. Referral to assessment: 17 days (pt choice excluded) and 33 days included Assessment to Diagnosis: 2.7 weeks (pt choice excluded) and 5.4 weeks included
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Financial Management
LQR2: Access: Increased number of people diagnosed with people diagnosed with dementia, and starting treatment, within six weeks of referral. Agreed target of 5% increase in performance on 2017-18 performance of 104 patients. The 2018-2019 target is 109 patients. July 2018: During July the service delivered referral to diagnosis within 6 weeks to 28 of the 49 pts reviewed.
Patient Journey Times for MAS
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Financial Management What next for memory services
• Is it appropriate to set access targets without capturing patient choice
• Benefit of an access target – streamlined process and removal of bottlenecks in systems. • Encourage collaborative working with commissions to review what your patients really want and
need - Go on the journey together and share learning
• Be the advocate for your patients
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