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Community Workshop Slides Post-diagnostic Support in Primary Care and Care Co-ordination Knowledge Exchange Lynn Flannigan / Julie Miller (Focus on Dementia) Amy Beck (NHS Dumfries & Galloway) Clare Serginson (Shetland HSCP) Becki Ballard (NHS Lothian) #Focusonnetworking Brenda Friel (Inverclyde HSCP) Enabling health and social care improvement PDS in Primary Care Scottish Government commission to Focus on Dementia Commitment 2 of DS3 3 year ‘innovation site’ programme until September 2020 . Nithsdale . Shetland . East Edinburgh. Programme aim To improve the accessibility and delivery of PDS, Commitment 2 of Scotland’s third dementia strategy laid out the aim to explore whether relocation of dementia expertise into primary care will make dementia support more accessible and “normalised” to individuals and families. Innovating to fit local context……. Post Diagnostic Support in Primary Care Amy Beck Performance Lead Nithsdale Enabling Health and Social Care Improvement Project Aim By the end of September 2020, 80% of people newly diagnosed with Dementia in Nithsdale cluster catchment area, who take up the offer of PDS, will have their PDS delivered in Primary Care. New Pathway What Has Gone Well Average wait from Dementia Practitioner (DP) referral to diagnosis, Gillbrae Medical Practice, pre and post introduction of revised • Reduction in pre-diagnostic pathway (excluding people referred for CT scan), GP appointments April'18 - Jan'20 60 • Increase in the number of people who can be 50 diagnosed by a Consultant 40 Psychiatrist 30 • Increase in the number of people diagnosed and 20 Number weeks of supported Introduction of new pathway 10 • Reduction in waits for diagnosis 0 • Reduction in waits to see a Date of DP Appointment Dumfries CMHT CMHN What’s Next • Phase 2 – Improve access to good quality PDS • Collaborative working with Alzheimer Scotland • Stabilise Phase 1 – Improve access to diagnosis and Phase 2 • Performance Programme Officer will commence post next month • Begin roll out of Phase 1 to the Wigtownshire Locality Reflections • Single Practitioner Model • Dementia Practitioners are from within existing resources • Dedicated Psychiatry Time • Support from MH Directorate and the Board Contact Details Amy Beck Performance Lead [email protected] Rachel Widdowson Performance Programme Officer [email protected] Lynda Forrest Performance Manager [email protected] PDS in Primary Care Shetland Clare Serginson Lead for Community OT Shetland HSCP Enabling health and social care improvement Progress update Our model of PDS – integrated into Community Occupational Therapy Successes and key findings. Challenges and barriers. Next steps. Any questions? Core Model: PDS integrated in Community OT Remote and small population of 23,000 Environment/ Geography Dementia Register 220 The front door for Health and Social Care in Shetland Service User Integrated Feedback Primary Care Key The PDS practitioner supported by Drivers the self management/enabling models of OT and the profile of the profession. Created an opportunity to develop Connecting People, new therapeutic interventions for Service Audit Connecting those with dementia in OT = Support HBMR pathway Audit and Ketso Focus Group 2018 Audit Results: 21 staff and 41 clients. A hidden service with little evidence of outcomes. What type of PDS do you want? Only 31% of individuals had a ACP • Reliable recorded. • Flexible – timing, support 35.7% of individuals had no PDS offered updates recorded. • Responsive - to the individual nature of the dementia experience Pathway Referrals: DAS Primary Route • We accept self-referral or GPs referrals from family/carer dependent on consent • Average 5 referrals per month Supported and Social over the baseline year accessed by PDS these services Care • Only 1 referral has come from outside of DAS – via OT 3rd HBMR Sector OT Successes • 92 individuals living with dementia & their carers have been supported “I have the opportunity to get • 75% increase in uptake things off my chest and get support from other services. • Average wait GP referral to diagnosis Your service seems to be the is 20 weeks main one who supports us and • Average wait referral to PDS to first frequently phones. You’ve contact is 25 days given me confidence to call • The PDS Practitioner is now an social work or other established permanent role in OT community care resources that I wouldn’t have done • Providing a PDS service the individuals previously”. want Challenges: – Differing systems – SC Vs Health – Getting Health Centre Staff to the table – Funding for the future – Responding to changes in staffing in a small community Next steps • Employing a PDS Practitioner for maternity cover – March 2020 Ensuring • Training further OT staff in HBMR – April 2020 Continuity • Continuing to use the Quality Improvement Framework Audit • Repeat Evaluation questionnaire – May 2020 Ensuring • Repeat Service Audit – March 2020 Quality • Creating presence on SIC website – June 2020 Shaping the future Any questions? Contacts: Enabling health and [email protected] social care improvement PDS in Primary Care East Edinburgh Becki Ballard Project Manager East Edinburgh Cluster Enabling health and social care improvement Dementia & Memory Support in general practice East Edinburgh GP Cluster Dementia & Memory Support in general practice Key Aims: • Create a systematic approach to providing PDS for people newly diagnosed with dementia so no one falls through gaps • Provide support to people with MCI via GP referral Dementia & Memory Support in general practice Key achievements: • DSF Role • Support patients at all 8 practices in Cluster • Everyone newly diagnosed is accounted for – GP lists and referrals • 188 people reviewed by DSF (out of total 391), with approx 62% taking up PDS • 90% say the Service has helped them ‘A lot’ • Time to first meaningful contact (list or referred) is currently 21 days & 6 days for MCI • 81% of MCI referrals go onto receive a diagnosis for dementia • Notes on practice system, incl. KIS & plan, which all staff see • 5 group work programmes run – collaborative • Range of training delivered eg age simulation, AWI, informed • Workbook Dementia and Memory Support - Personal Plan Name: Michael Brown CHI: XXP4887 Surgery: Portobello Medical Practice Preferred GP: Dr Finn Date: 15/08/2018 Life Story Identity/Values & Dementia diagnosis & Dementia Medication Interests Understanding of Illness Born and raised in Edinburgh, Memantine lived most of his life in Granton He used to be very Alzheimer’s. Little insight into diagnosis. before moving to Portobello 2 social but that has Environment years ago. Worked in a changed a bit since his befriending service that diagnosis. He still sees Lives with wife. Safe, Carer Needs promoted social events within the value in clutter-free home the community. He is now maintaining social His wife is managing environment. Have retired. Has one daughter who relationships. He well at the moment. discussed possible lives just 5 minutes away and is enjoyed driving but She is supported by her home adjustments for very supportive. has given that up now. daughter and sister. I the future and has also referred her to been seen by an OT. Vocal on 15/08/2018 for future support. Health – physical (incl daily Current Additional Key Information, incl Future Wishes living), mental, emotional Strengths Difficulties POA for Welfare & Finances held by his wife Jean Independent with personal Enjoys the Poor care Farmer company of memory I have requested a Social Care assessment, Struggles with performing other which affects every day tasks such as appointment on 02/10/2018 people activities of I have referred him to Cottage Club day centre, he cooking (his wife needs to Acceptant daily living remind him to eat) now attends on Fridays of support Poor balance Preferred place of care is his own home Struggles with his balance, and advice notified GP regarding; no other emotional or mental issues Final Review Date: Service End Date: Dementia & Memory Support in general practice Areas to further develop • Refining Service • Training Programme • Resources • Advising on local Pathway • Future funding Dementia & Memory Support in general practice Lessons – what helps • Regular Steering Group - good representation • Committed Cluster Quality Lead - giving direct link to GPs • Dedicated Project Manager with experience of setting up such services • IT support in GP practices • Experienced DSF Dementia & Memory Support in general practice Lessons – what hinders • 8 practices • When I.T. doesn’t work • HR • Lack of practical support eg graphics, admin • Local Pathway • Financial uncertainty Dementia & Memory Support in general practice Feedback • Pointed me in the right direction • Everyone has been very helpful and very much appreciated. Thank you. • Helped me in the role I now have caring for my mother. • There did seem to be quite a lot of information available and it was helpful and time saving and saved a great deal of physical effort on my part when I was at a low ebb. • Very handy to be based locally • The support given has been great in helping to understand my Mum’s illness. The groups are great. • Knowing this service is based at the GP gives the feeling of local support • Not having to go through the Social Work to speak to someone local who has knowledge and is there to help and advise and find out information that can be useful and beneficial, makes if very informative and easy! • Knowing someone is there if and when needed! Knowing there is help – care, clubs, meals - takes some of the pressure off •It has been good to have someone to talk to. We are sorry it is not for longer, it seems a shame. Care Co-ordination • In 2012 Alzheimer Scotland developed the 8 Pillars Model • Tested in 5 HSCPs across Scotland as part of DS2 • Scottish Government commission to Focus on Dementia Commitment 4 of DS3: . Review of literature . Appreciate Inquiry Midlothian . 2 year programme until March 2021 – Inverclyde HSCP Care co-ordination Care co-ordination can mean different things to different people. It is a broad and relatively ill-defined concept.
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