Cornwall’s Joint Commissioning Strategy

1. Cornwall’s Joint Commissioning Strategy Presented by: Carol Williams, Director of Service Improvement Bev Chapman, Clinical Lead & Specialist Dementia Nurse October 6 2009

2. Commissioning for Dementia: The last 12 months 07/08 Joint Strategic Needs Analysis Dementia is a shared Council/PCT strategic priority May 08 ClinicalDementiaLead appointed Time Jul 08 Joint Commissioning Plan Aug 08 Service ImprovementProgramme World Class Commissioning Outcome Oct 08 National Dementia Strategy Feb 09

3. Quantifying Needs • 8,213 people living with dementia in Cornwall and the Isles of Scilly • 2,645 people on GPs dementia registers in August 08 • World Class Commissioning ambition to increase number of people on registers to: • Aug 09 – 3,352 • Aug 10 – 3,724 • Aug 11 – 4,096 • What about carers? Perhaps 4,100 living in Cornwall or 1,500 requiring help by Aug 09? • We need to commission sufficient services for at least the number of people on dementia registers

4. High Complexity Case Management Medium Complexity Disease / Case Management Low Self Care support / Management Dementia Care Advisors? Care Pathway Segmentation Prevention Awareness Recognition Assessment Opportunities for providers exist all along the pathway Diagnosis Case Mgmt & Treatments Crisis End of Life

5. Principles of commissioning ‘PEOPLEwith dementia’ • Dementia a long term condition: chronic and progressive • Overlapping physical, mental, health and social needs • Early diagnosis, continuity of care and more choice • Younger people with dementia • People with learning disabilities

6. Principles of Commissioning (cont) • More community based services promoting independence, delaying or preventing admission to care home/hospital • Integration / joining it up is the only way we can make the best of what we’ve got • Locality commissioning • Low intensity can mean high impact – eg Assistive Technology • Thinking smarter about the connections between different providers – e.g. the relationships between GP practices, a dementia nurse, a social worker and a care home. • Care Homes are people’s homes too.

7. Long Term Conditions • Understand our population • Early identification of need • Promote self management, • Optimise quality of life and self esteem • More prevention, less crisis management • More responsive • community health and social care

8. Sacred Cow Philosophy People with dementia have needs that can be labelled: ‘health’,‘social’ ‘primary’ ‘secondary’ Dementia is ‘Older People’s Mental Health’ Older People’s Mental Health are ‘secondary’ care services

9. Cow slaying logic (1) • Dementia a long term condition: chronic and • progressive • So: overlapping physical, mental, health and social needs • What about younger people with dementia? • What about people with learning disabilities? • Why ‘mental health’?

10. Primary Care Non- Community Services (People can’t stay In own home) Social Care Health Care Secondary Care Divided by a common language Community Services (People in own home) GPs Locality – eg Newquay

11. More Bad Language People with dementia are ‘Demented’ ‘Dementing’ ‘Victims’ ‘Sufferers’ ‘Wanderers (without purpose)’

12. Value the PERSON with dementia “Please don’t call us ‘dementing’ – we are still people separate from our disease, we just have a disease of the brain”. If I had cancer, you would not refer to me as ‘cancerous’ would you? Our labels seem to mean so much – am I Alzheimer’s Disease or fronto-temporal dementia, or simply someone with a ‘dementing illness’. All these terms labels us as someone without capacity, without credibility as a member of the community. How about separating us from the illness in some way? How about remembering we are a person with progressive brain damage” Christine Bryden, “Dancing with Dementia”, 2005

13. Curing Sacred Cow Disease • Make dementia ‘everybody’s business’ rather than “somebody else’s business” • Focus on prevention – physical health check – vascular checks to prevent vascular events • Improve awareness and recognition of dementia amongst GPs, health and social care professionals, including care homes • Increase the number of people receiving an early diagnosis and an annual health check.

14. Prevention Awareness Commissioning integrated pathways rather than organisations • The Menu • Information • Books on Prescription • Cognitive Stimulation Therapy • Creative therapies • Peer-Support • Memory Cafes • Assistive Technology • Sensory Therapies • Reminiscence Work • Carer Education • Domiciliary care • Respite Care • Advocacy • Care Home/Hospital Recognition Assessment Diagnosis Case Mgmt Tiered Menu of Interventions Unscheduled Tiered Menu of Interventions End of Life Simple pathways and overlapping services

15. Work so far • Memory Cafes flourishing • Awareness raising campaign • Education and training • Making it easier to get a diagnosis – 19 Memory Clinics across the county • Newquay Integrated Care Pilot • Dementia Liaison in Care Homes • Carer Education Programme • Advocacy • Arts for Health • Adult Placement for people with dementia Swaps

16. Public awarenessour memory bus

18. What does this mean for providers? • Dementia care is a ‘growth market’, but not for more of the same - greater emphasis on early intervention, high volume, low-cost interventions. • Fundamental change essential. Opportunity for existing providers to rethink corporate identities, business models and their role in delivery. • Expect new providers with new types of expertise to enter the market in response to new demands (e.g. Extra Care Housing and GPs) • Competition for business increasing. But, so are opportunities for greater co-operation, collaboration and sharing of resources (knowledge, staff, technology, buildings).

19. What does this mean for providers? • More emphasis on defining and rewarding quality. • Currency ‘person-centred care’ not ‘units of care’. • New income opportunities for the best providers. • Providers, who can evolve quickly into a new breed of ‘Dementia Specialists’ and who can deliver whole-life, person-centred dementia care in a range of settings will prosper • There has never been a more exciting time to be a dementia care provider in Cornwall

20. Good opportunity for: • Commissioners informing • Plans • Progress • Business Opportunities • Commissioners LISTENING! • Bringing the experts together: collaboration and best practice sharing • Arts for Health • Assistive Technology

21. The Newquay Integrated Care Pilot What we did and early learningRegistered Pop 23,000Anticipated Dementia: 361

22. Dementia Liaison Pilot • Trial the Hospital Liaison model in the community (Care Homes, Community Hospital and GPs) • QOF Health-checks (Community & Care Homes) • 3 month pilot in 12 care homes – led to commissioning of dementia liaison service. Finding the undiagnosed. • Partnership with pharmacists – medication reviews

23. GP Led Memory Clinic • Education – anticipation of successful Dementia Academy 27th March • Opportunistic screening with flu jab • Recognition, assessment, diagnosing and prescribing cognitive enhancers • Complementary and in addition to existing assessment, diagnosis service, which still provides ‘back-up’ and is partly moving to a Memory Clinic model. • Case management

24. What did Newquay tell us? • Over 50 patients with undiagnosed dementia identified and registered on QOF registers • 104 QOF Health Checks completed • 27 Psychiatric Medications discontinued (anti-psychotics, night sedation, benzos and depots). • 15 changes to physical medications • 8 Blood Tests • 5 regular blood pressure reviews • 19 pain assessments and treatment • 10 Dietary supplements and weight monitoring • 6 End of Life Care Plans (preventing admission to acute hospital

25. Dementia Liaison Practitioners’s in Care Homes • Fortnightly review of all care home residents • Providing evidence based education and training • Close working relationship with G.P as decision maker • Annual QOF health check • Crisis prevention • Easily accessible • Acute Hospital admission avoidance • Stabilising needs to avoid distressing move to other care facility • Family support • End of Life care in line with Gold Standard Framework • Reduction of anti-psychotic medication • Risk assessment

26. Annual QOF Health Check • Blood Pressure • Cognitive Assessment • Medication • Nutrition • Weight • Continence • Activities of daily living • Mobility • Falls • Mood • Pain • End of Life • Difficult to manage behaviours • Plan

27. IMPROVED HEALTH OUTCOMES Case Study – Mr G End of Life Pathway

28. Newquay Case Management Outcomes • QOF registers • Prevalence 361 • Sept 08 136 • April 09 207 • Sept 09 244 • 67% of expected prevalence against 37% county wide • Case management 131 with care plan in community • 113 with care plan in care home

29. 2010.... Tele helpline Memory manual Community liaison expansion Case management rollout Increase QoF registration Health checks for all/ health promotion Reduce hospital admissions/crisis Gold standard palliative care. Partnership working social/care all sectors.