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Models of memory assessment
Dr Jill Rasmussen
Declarations of interest:
NHS• GP East Surrey• SCN SE Coast Clinical Lead Dementia• Honorary Research Fellow Wolfson Institute King’s College London• Co-developer of MoodHive (Depression Anxiety Pathway)
Royal College of General Practitioners• Clinical Lead Dementia • Chair Learning Disability Special Interest Group• Member Dementia Roadmap Steering group
Consultancy / Advisory Boards / Speakers Bureau• Alzheimer’s Society, Cerestim Ltd, Chase Pharmaceuticals, Edmund
de Rothschild, Eli Lilly, Lundbeck, Ono, Otsuka, Pfizer, Roche, Servier, Wellcome Trust
• psi-napse
Dementia diagnosis pathway models:Potential options
• Specialist-only multidisciplinary diagnostic/research service• Specialist one-stop-shop plus GP supported diagnosis• CMHT nurse-led diagnostic service• GP incentivised diagnosis with enhanced CMHT support• GP incentivised diagnosis with specialist support
Dementia diagnosis pathway models:Gnossall model
• Secondary PLUS primary care expertise• Community based eldercare facilitator; supported by practice
manager, and secretary• More familiar to patient, family, carers• Access to primary care resources (history, test results, IT)• Evaluated positively; improves quality, costs• Gnosall Health Centre. Gnosall Memory Clinic:
the basics. May 2013
Dementia diagnosis pathway models:Bristol: dementia diagnosis and care in primary care
History
Improving the pathway for people with dementia became a priority around 2010/11. It was identified that diagnosis rates were low and that there were:
• Bottle necks at the memory clinic as everyone was referred there • Long waiting times for the memory clinic • People delayed in accessing treatment • Low diagnosis numbers, circa. 38% • GPs who had become deskilled at managing and supporting people
with dementia
Dementia diagnosis pathway models:Bristol Model
Pilot scheme in 11 practices
• Workshop held to understand more about the pathway • View that GPs may be able to diagnose some cases of dementia in
primary care • Scheme was piloted in 11 practices • Memory nurses shifted their work from secondary care to primary
care• The GPs were supported to diagnose straight forward dementia
cases• The pilot was evaluated by University of West of England.
Dementia diagnosis pathway models:Bristol Model
Evaluation
• The results from the evaluation were positive and as such, the following was agreed;
• The service should be rolled out to the whole of Bristol, supported further by an enhanced service.
• Practices should be paid for the clinical time to undertake the work that had previously been done in secondary care.
• A Memory Clinic should remain in place for complex dementia cases.
Dementia diagnosis pathway models:Bristol Model
Current Position
• Developed by a multi-disciplinary team; included GP’s, commissioners, memory service and medicines management team.
• Medicines management support crucial as work involved changing the way practices prescribe
o Templates developed to support transition.• EMIS web templates developed to ensure consistency .• Practices paid to diagnose dementia based on cost of clinical time
to do the work. Diagnosing dementia not part of GMS / PMS contract;
o work previously delivered in secondary care.
• Enhanced reviews also funded (over and above QoF requirements.o Model encourages practice nurses to take the lead
• GP and practice nurses attend dementia training each year.
Dementia diagnosis pathway models:Bristol Model
Key Learning Points
• Clinical leadership/ownership to drive changes • Support from Medicines Management vital • Requires a good level of buy in, support and time to deliver changes
– not a quick option • Proper community support required along the pathway • Training needs to be in place for primary care • Services needed post diagnostic support so
that people living with dementia and GPs are clear of the benefits of diagnosis.
Dementia diagnosis pathway models:Bristol Model
Dementia Wellbeing ServiceCommissioned in 2014 to support this work. It will:
• Shift dementia from predominantly secondary care to primary care. • Focus on prevention and care planning. • Have extra capacity in the services. • Provide on-going support with dementia navigators • Support Primary Care to diagnose dementia • Have a one stop memory clinic for complex dementias
Results• 62% diagnosis rate; 5th best in England • 80% of cases now diagnosed in Primary Care • No delays for memory clinic due to capacity
Dementia diagnosis pathway:Pros specialist service
• More suitable for MSNAP accreditation.• One-stop stop waiting time by reducing need for follow-up,
o Includes neuroimaging.
• Includes assessment of atypical / complex /early onset presentations
o Needs to include neurologist• Well established in many areas, motivated to succeed.• Quality can be assured and delivered consistently
o May need monitoring• Potential for Involvement in research improves cost-effectiveness
and patient support during & after diagnosis.
Dementia diagnosis pathway:Cons specialist service
• Stigma of referral to Mental Health Services• Longer time from referral to diagnosis • More expensive:
o Too standardised to save costso Not individualised
• Not necessary for more advanced presentation• Non-dementia diagnoses divert resources away from dementia
o Physical illness, depression, MCI• Potentiates view that management of dementia is a specialist
condition
Dementia diagnosis pathway:Pros primary care service
• Avoids need for initial referral to specialist services• Convenient
o Geographicallyo Patients know us and We know them
• Shorter waiting times• Potential to be cheaper• Access to patient information; easier to code / include on registers • Compatible with primary care model of management of long term
conditions• Specialist services reserved for atypical/complex and crisis cases
o Psychiatrist and neurologist
Dementia diagnosis pathway:Cons primary care service
• GPs are generalists not specialists• Need to see more patients to develop / maintain skills, consistency,
reliability • Requires brain imaging access by GPs• Financial incentive to over-diagnose: risk of harm• Initiation of AChEIs / memantine, currently contrary to NICE
o May change
• May require financial incentive which reduces cost-effectiveness• May require specific training:
o GPwSIo MSC course
NHS five year forward view: lessons from the United States in developing new care models:
Background:Managed care evolved into integrated delivery networks in the 1990s, with a focus on better coordination of care as a means of improving quality and containing costs.
EvaluationMost networks failed to deliver savings for reasons including:• Poor information technology• ineffective coordination of care for pts with complex chronic needs.• bolted together existing providers & processes rather than truly
integrating clinical care.
Ref: BMJ 2015;350:h2005 doi: 10.1136/bmj.h2005
Prospects for the NHS in England in the next parliament:
Investment and reform should be at the heart of the new government’s programme
Prospects for improved productivity
To make progress, •Providers must do more to engage staff in improving productivity•Politicians must be realistic about the time needed to show results.•Finding solutions depends on transforming how care is delivered.
o Fragmentation between providers is a major cause of treatment delays and waste.
•This requires the development of new models of care and the removal of barriers to their implementation.
Ref: BMJ 2015;350:h2541 doi: 10.1136/bmj.h2541 (Published 11 May 2015)
Commissioning New Models of Dementia Care:Five Top Tips
• Vision first, model second• Understand your workforce economics as this drives the feasibility
of the model• Consider developing integrated care models with primary care,
acute hospital, secondary care, voluntary sector and local authority• Dementia clinical lead for CCG• Engagement with GPs and patients, families and carers• Engagement with m ALL stakeholders:
o Health, social care, third sector
Dr Jill Rasmussen
Dementia Clinical LeadKSS Strategic Clinical Network
kssahsn.net
