The Balance of Care Groupin association with Lincolnshire Partnership Trust, Lincolnshire PCT, United Lincolnshire Hospitals NHS Trust, Lincolnshire County Council

Tackling Dementia Care as a Whole SystemTom Bowen, Paul Forte & Dr Chris Foote

NAO Conference, London, 12 July 2007

2

Pre admission

Pre admission Admission Diagnosis Treatment Discharge Re-admission

Social details

alone, carers, residence

Risk factors:

age, drugs, co-morbidities,

psychiatric/

dementia, falls

Preventative care

Disease managementManaged populations

Source of referral

Time

Waiting time

Route

Decision maker

Reason for admission

Alternatives to acute admission setting

Admission diagnosis

Inpatient diagnosis

Delays in diagnosis

Chronic disease

Alternative access for diagnosis

Delays in therapy

Alternative settings for therapy (especially rehab)

Discharge planning

Delays in planning

Delays in execution

Alternative sites for discharge

‘Revolving door’

Avoidable e.g. chronic disease management

Alternative sites for readmission

A whole system perspective

3

The Lincolnshire bed usage survey

• To identify the number and types of inpatients currently receiving hospital care (acute and non-acute) who might potentially have:– been treated elsewhere and avoided admission– required admission, but could now be treated elsewhere– particular emphasis on people with dementia

4

The Lincolnshire bed usage survey

• To identify the number and types of inpatients currently receiving hospital care (acute and non-acute) who might potentially have:– been treated elsewhere and avoided admission– required admission, but could now be treated elsewhere– particular emphasis on people with dementia

• Point prevalence survey on 29 November 2006– All medical and orthopaedic inpatients (667)– All intermediate care inpatients (121)– All OPMH inpatients (75)

5

Age Distribution of Patients by Type of Bed (N=860)

0

50

100

150

200

250

Under 65 65 to 74 75 to 84 85 & over

No

of p

atie

nts

A -acuteB intermediate careC - OPMH

6

Proportion of Patients with Mental Health or Cognitive Issues (N=863)

Dementia13%

Confusion14%

Anxiety/depression8%

Psychosis2%

Substance Misuse2%

Other1%

No mental health issue60%

7

Location of Patients by Mental/Cognitive Issue (N=344)

0

20

40

60

80

100

120

140

Demen

tia

Confus

ion

Anxiet

y/dep

ress

ion

Psych

osis

Substa

nce M

isuse

Other

No

of p

atie

nts

OPMHIntermediate careAcute

8

Occurrences of comorbidities in dementia patients

0

5

10

15

20

25

30

Heart

failur

eIH

D

COPD

Diabete

s

Parkins

ons

Hypert

ensio

n

Arthriti

s

Cance

r

Cerebrov

ascu

lar

No

of o

ccur

renc

es

OPMHICacute

9

Comorbidities for Patients with Dementia (N=111)

0

5

10

15

20

25

30

35

0 1 2 3 4 5Number of comorbidities

No

of p

atie

nts

OPMHICacute

10

Assessed risk of 'confusion' patients having dementia (N=119)

0

10

20

30

40

50

60

High Medium Low

Assessed risk of dementia

No

of p

atie

nts

OPMHICacute

11

Appropriateness Evaluation Protocol

On admission• Severity of illness

eg unconscious, unable to move (fall), acute bleeding• Intensity of service

eg surgery + general anaesthesia, regular monitoring, IV therapy

On day of care• Medical services• Nursing services• Patient condition

eg acute confusion, other acute states, coma, fever

12

Percentage of Acute Inpatients within AEP Criteria(Dementia = 65, all other = 602)

83%

32%

85%

53%

0%

20%

40%

60%

80%

100%

on admission on day of care

% o

f pat

ient

s w

ithin

AE

P c

riter

ia with dementiaall other

13

Alternatives to Continued Stay for Acute Hospital Patients with Dementia (N=43)

0

2

4

6

8

10

12

Own Hom

e

Home &

Socia

l Care

Home &

Gen

eral H

ealth

Care

Home &

Reh

ab S

upport

Home &

Spec

ialist

Nurse

Acces

s to O

utpati

ents

Non A

cute

Bed &

Therapy

Non A

cute

Bed

Home &

Spec

ialist

Home C

are

Home &

MH S

upport

Home &

MH R

ehab S

uppo

rt

Non A

cute

Bed &

MH T

hera

py

Acute

MH Bed

EMI Con

t Care

Bed

Other

No

of p

atie

nts

Quick dischargeRemaining

14

Alternatives to Continued Stay for OPMH Patients with Dementia (N=34)

0

2

4

6

8

10

12

14

16

Own Hom

e

Home &

Socia

l Care

Home &

Gen

eral H

ealth

Care

Home &

Reh

ab S

upport

Home &

Spec

ialist

Nurse

Acces

s to O

utpati

ents

Non A

cute

Bed &

Therapy

Non A

cute

Bed

Home &

Spec

ialist

Home C

are

Home &

MH S

upport

Home &

MH R

ehab S

uppo

rt

Non A

cute

Bed &

MH T

hera

py

Acute

MH Bed

EMI Con

t Care

Bed

Other

No

of p

atie

nts

Quick dischargeRemaining

15

Some Key Points• 111 out of 863 patients surveyed (13%) had a

recorded dementia diagnosis• 65 were in acute hospital• There may be substantial under-diagnosis or

under-recording of dementia• Majority of acute hospital patients with dementia

were outside AEP criteria on the day of the survey• Potential alternative care settings cover a wide

range of services, specialist coordination may be needed

• Demand for rehab support for people with dementia

16

17

Source of Referral for Patients with Dementia - Acute (N=65)

Referral by GP18%

Seen by GP17%

99943%

Self2%

Other Hospital

2%

Other/nk18%

Source of Referral for Patients with Dementia - OPMH (N=40)

Referral by GP32%

Seen by GP5%

Other Hospital

15%

CMHT18%

Crisis Team8%

Other/nk22%

18

Comorbidities for Patients at High Risk of Dementia (N=30)

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4 5Number of comorbidities

No

of p

atie

nts

OPMHICacute

19

Preferred Alternatives to Admission for Dementia Patients (N=36)

0

1

2

3

4

5

6

7

8

Home &

Soc

ial C

are

Home &

Gen

eral

Health

Care

Home &

Spe

cialis

t Hom

e Care

Non A

cute

Bed

Non A

cute

Bed &

Therap

y

Carer R

espit

e

Home &

MH S

uppo

rt

Psych

OP

Non A

cute

Bed &

MH The

rapy

EMI Con

t Care

Bed

No

of p

atie

nts

OPMHICacute

20

Admission criteria of ULH patients with dementia (N=65)

0

5

10

15

20

25

0 1 2 3 4 5

Number of comorbidities

No

of p

atie

nts

otherA1outside AEP