nfhd 8 feb 2012 - dr les rudd harold proctor - · pdf filenfhd 8th feb 2012 - dr les rudd...

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1000+Lives Programme Dementia target &

improving hip fracture care outcomes.

NFHD 8th Feb 2012 - Dr Les Rudd

Harold Proctor

Driving integration of physical & mental

health care to improve outcomes

• Mental disorders often go unrecognised in patients with physical illness

• Impede recovery from a physical illness & increase mortality rates

• Mental health problems increase the costs of physical healthcare

Survival after hip fracture…

(Nightingale et al 2001, Lancet, vol. 357, no. 9264, 1264-126)

As for length of stay…

(Holmes & House 2000, Psychol Med vol. 30, 921-929)

A bit of epidemiology…..

From: Who Cares Wins RCPsych 2005

National Dementia Vision

for Wales (2011)

“The Welsh Assembly Government has made a commitment to make immediate improvements to dementia services in Wales by taking forward the priority actions that have been identified and delivering the following commitments”

WG Dementia Care Policy

• WG National Dementia Vision for Wales – launched 16th February Dementia Supportive Communities

• WG 2011-12 Annual Quality Framework (AQF) priority for implementation of the Dementia Care Intelligent Target.

• WG Dementia Care 1000+Lives Targets – 5 targets 2010. Service improvement, not performance management targets.

• Dementia Action Plans 2010-2015 – Four plans focussing on:- – Improve quality of general hospital care

– Reduce inappropriate use of anti-psychotics

– Improved early diagnosis and timely interventions

WG new £1.5 m funds for

dementia care – 13th July 2010 • Young Onset dementia services

• Dementia Advisor posts – every CMHTE

Plus

• DSDC ‘train the trainers’ prog to April 2012

• Wales Dementia Helpline available 24/7

• Book prescription Wales + 4 dementia books

• With Alzheimer’s Society

– Dementia information packs for issue to

patients diagnosed with dementia

– National campaign to raise awareness

RC Psych

1000Lives+ - ‘How To Guides’

Dementia Target & sites 1) Making and sharing the diagnosis

reduce time between onset of symptoms & diagnosis being communicated

2) Dementia in the general hospital Improved quality of general hospital care for people with

dementia and reduced length of stay

3) Use of anti-psychotics Reduced inappropriate use of anti-psychotic medications in

accordance with NICE/SCIE guidelines.

4) Support for care-givers Improved support for care givers

5) NHS in-patient care (mental health units) Improved quality of care

DGH Cognitive Impairment Pathway

• Designed to support the treatment and care management for people with cognitive impairment and dementia who enter the emergency and acute medicine stream.

• Begins at the point of admission and aims to better identify patients with cognitive impairment and dementia and following them through their hospital journey, to the point of discharge planning.

• Specifically developed to support the UHB’s response to the Dementia Intelligent Target for General Hospital Care.

• Significant audit activity further to implementation of the Pathway, as high level indicators emanating from the Pathway will be reportable under the All Wales Quality Framework.

Alistair Burns, DOH National Clinical

Director for Dementia

• “One of the aspirations of care of people with

dementia, the thrust is to improve the recognition of dementia and the suggestion is that two abbreviated mental test scores should be administered – one on admission and one post op

• develop the existing dementia audit into a dementia database in the same way as the hugely successful National Hip Fracture Database

AMTS

ATMS score – cut off below 6

• a consistently low score would suggest further investigations and assessment for dementia,

• a score which was high on admission and then became low would suggest the development of a delirium,

• a score that was low and then became high suggests recovery from a delirium

• a persistently high score, to all intents and purposes (but not overriding clinical judgement) excludes the presence of dementia or delirium

Dementia target 3

Anti-psychotic medications

Targets 3

• Target Three: Community mental health services for people with dementia (including those in care homes) - Reduced inappropriate use of anti-psychotic medications in accordance with NICE/SCIE guidelines. – Number of people with dementia prescribed anti-

psychotic medication

– Proportion of people with dementia who are on anti-psychotic medication where review within 3 months

– Proportion of people with dementia who have been on anti-psychotic medication for >9 months

Target 3 – Interventions % compliance with this ‘care bundle’

1. Full discussion with patient &/or carers about possible benefits & and risks of treatment.

2. Assess for capacity and where person with dementia lacks capacity, follow ‘best interests’ process regarding use of antipsychotics

3. Anti-psychotic medication to be used with people with dementia after other approaches have been tried (see NICE-SCIE, 2007), unless person at immediate risk of harming self or others or severely distressed

4. Medication to start with low dose, be time-limited and aimed at specific, recorded and quantified target symptoms and reviewed at least every 3 months, and reduced as soon as possible; the review should consider: side-effects, changes in cognition, changes in target symptoms

5. Alternatives to anti-psychotic medication considered. Other approaches to include a full assessment, including physical health, pain, depression etc. (with multi-disciplinary team input)

Depression Target

• General Hospital settings

Content Driver Interventions

To improve rate of detection of, consistent measurement & appropriate treatment intervention for individuals with depression to achieve their optimal level of functional

recovery.

First point of contact – diagnosis & symptom recognition

Appropriate intervention for mild/mod depression Stepped care levels 1-2

Appropriate intervention for mod/severe depression Step care 3-5

Use two question screen for target high risks groups in hospital settings Finding little interest & pleasure in

doing things

Feeling down, depressed or hopeless

Administer the PHQ-9 for patients who score ‘yes’ to the two questions

Refer patient for further assessment if they score above threshold on PHQ-9

Watchful waiting for 2 weeks

Use of ‘Info prescription’

Bibliotherapy, self help groups, internet support

Psychological treatment for 6-8 sessions over 10-12 weeks , eg problem solving therapy; brief CBT; counselling

Referral to psychiatric liaison service

Referral to primary care or CMHT

Treat in gen hospital with meds

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leslie.rudd@wales.nhs.uk

078 666 79064

• Rhyngrwyd/Internet: www.iechydcyhoedduscymru.wales.nhs.uk www.publichealthwales.org

• Mewnrwyd/Intranet: nww.publichealthwales.wales.nhs.uk

• Twitter: www.twitter.com/1000livesplus

• www.dementiahelpline.org.uk