Stephen Lithgow - PDS Emerging Themes in Glasgow

Post Diagnosis Support.
Emerging Themes in Glasgow
Stephen Lithgow
Dementia Support and Development
Lead. GG&C NHS.
7th March 2014.
Webex Objectives
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Discuss a working model of PDS.
Consider a PDS pathway and
delivery mechanisms.
Identify strengths and weaknesses
of a PDS model.
Explore common issues.
Problem solving.
Overview
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HEAT Target.
Glasgow South PDS.
Driver diagram.
Key Issues.
Discussion (Approx 30 mins).
HEAT Target
The HEAT Target
“ To deliver expected rates of
dementia diagnosis and by
2015/16, all people newly
diagnosed with dementia will have a
minimum of a year’s worth of postdiagnostic support coordinated by a
link worker, including the building of
a person-centred support plan”.
The HEAT Target
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‘Link worker’ - Could be 3rd sector
link worker, mental heath staff,
Social work or other worker who
may deliver support for year.
Use 5 pillars approach.
Personal plan.
Must be trained to Enhanced Level
of Promoting Excellence.
5 Pillars of Support
The new commitment informed by
Alzheimer Scotland “5 pillar” model.
- help to understand the illness and
manage symptoms;
- support to stay connected to the
community;
- peer support;
- help with future decision-making;
- and developing a personalized care plan
for their future care.
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Glasgow South Sector
Glasgow South Sector.
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Population 220,000 (30,00 over 65).
Dementia Calculator 2646 prevalence
(Eurocode).
1403 on QoF. 53% of prevalence
diagnosed HEAT target.
327 Incidence. (New clients per year).
Require 6-7 W.T.E staff.
Based on caseload approx 50.
Delivery Model
NHS and 3rd Sector.
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NHS/3rd Sector link workers.
CMHT (CPN/OT) staff and Alzheimer
Scotland.
Based in 2 locations. Elderpark and
Shawmill.
One additional Alzheimer Scotland
worker in each team.
Change Fund.
What happened.
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301 clients in first year.
Alzheimer Scotland link worked
approx 100.
NHS (CPN) link worked 200.
Severity. At least 42% mod to
severe. (20% unknown).
Caseloads max around 50.
What happened.
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Monthly data returns started.
Personal plan developed. Started
using an outcomes approach.
Raised £371,000.
Piloted supported self management.
Driver Diagram
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Pathways to diagnosis and post diagnostic
support are clear and understood.
Effective partnership governance of the
delivery of the PDS Target.
Data capture and reporting systems in
place.
Service Redesign Opportunities have been
maximised.
Person centred care approach underpins
delivery of all PDS services. (Outcomes).
PDS Pathway. Example.
Data Capture
Monthly returns.
 Named person in each sector.
 Shared drive for Health Board.
 Link workers putting data on
system.
 Ongoing errors.
 Co-morbidity. Relative need.
 PDS Follow up. Longitudinal.
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Person Centred Care.
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Outcomes and NHS staff.
NES and SSSC training.
Personal Plan.
Using Outcomes. Quantitative and
qualitative recording.
Partnership Governance
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Alzheimer Scotland staff co-located in
OPCMHT.
Honorary Contracts.
Access to Metaframe (NHS e-mail,
PiMS, and shared drive).
Patient information. Need to know
basis. Consent.
Overarching Health Board
agreement.
Service Redesign
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Not like Dem Demonstrators.
‘Minimal disruption’ approach.
Adding on resource to existing team
and new skill mix.
Use existing health IT, buildings,
resources.
Some Key Issues
Issue: Assessment & Allocation of
Link Worker.
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Diagnosis- Traditionally cognitive
and some functional assessment.
Often more complex needs.
Indicator of Relative Need (IoRN).
Allocation. Complexity/need but
how?
Less complex 3rd Sector. More
complex Health.
But depends on existing team mix.
Issue: Dementia Severity and Comorbidity.
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35% early.
39% clients moderate.
4% severe.
Not known 22%.
Physical frailty and co-morbidity
across PDS client group.
Light touch theory and often more
complex More than 5 pillars.
‘More 8 pillars....’
Issue: Promoting Excellence
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Should be at Enhanced Level.
Benchmarking still needs to be
done.
Benchmarking tool for link workers?
Capture qualifications/training and
work experiences.
PDS training. Outcomes training.
Sensory impairment.
Issue: Link Worker Case Load.
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Ceiling around 50.
Needs to consider
complexity/workload with caseload
weighting.
3rd Sector clients should be less
complex but not always.
Danger of overwhelming staff.
Allocation & throughput important.
Issue: Link worker role
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Supporting more than 5 Pillars.
Complexity. Overlap with proposed
8 pillar/ongoing care.
Risk of taking on Social Work role.
Clearer role for 3rd Sector link
workers.
Dual role for CMHT staff. Nurse or
Link worker?
Understanding of role is emerging.
Issue: Personal Plan
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Example.
Done from ‘scratch’.
Outcomes difficult.
Staff feel there is repetition.
Issue: Personal Plan.
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Consider Progress/process to plan
and final plan.
What does a plan look like?
Some clients don’t want one.
Pilot version. Biographical. 5 pillars.
Risk enablement. Outcomes
framework.
3rd Sector appeared to work.
Nursing feedback. Survey Monkey.
Issue: MacMillan/Alz Scot
Long Term Conditions.
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Summary of financial gain to November 13
[Not Specified] £22,965.40 (5 clients)
Attendance allowance £197,571.55 (50 clients)
Blue Badge Application £276.00 (3 clients)
Carer's Allowance £16,220.88 (7 clients)
CHSS Grant £1,350.00 ( 6 clients)
Council Tax Benefit £24,151.70 (44 clients)
DLA - Both £12,617.80 (2 clients)
DLA - Care £34,288.80 (7 clients)
Employment Support Allowance £5,538.00 (1 client)
ESA (Contribution Based) £5,538.00 (1 client)
ESA (Income Based) £14,957.80 (2 clients)
Funeral Payment £1,237.00 (1 client)
H B/Local Housing Allowance £4,115.80 (1 client)
Pension Credit £20,195.73 (4 clients)
Scottish Welfare Fund £670.00 (3 clients)
Vehicle Duty £300.00 ( 2 clients)
Total £371,095.26 (140 clients)
Issue: Outcomes
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Back to front approach.
Personal Plan with Outcomes.
But staff not trained in Outcomes.
Training piloted by NES and SSSC.
Can Personal Plan or documentation
support/measure outcomes?
Or more about conversations and
how it is recorded?
Issue. Role of CPNs.
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Dual role.
CPNs shouldn't be doing 2/3 of PDS
link working.
Maintain resources for more
complex clients and possible 8
pillars.
Allocation on need.
Using band 4 staff in North West.
Integration with SW.
Issue: Role of AHPs
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OT staff didn’t linkwork.
Provided aspects of pillars through
supported self management.
Two 8 week groups. Practical
solutions to managing memory.
Peer support. Other agencies.
Need for AHPs re co-morbidity and
proposed 8 pillars model.
Best use of AHP resource?
Positives
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Vascular dementia
More consistent approach.
Moving to Outcomes.
Greater understanding of roles.
Self management feedback. (Carer/client)
Financial.
Staff have mixed views.
Issue: Could do better
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Outcomes. May take years to
embed.
Assessing real impact. Qualitative.
PDS service mix.
Clear written protocols on
assessment and allocation, roles of
link worker.
Allocation by cognitive enhancers.
Learning disability and YOD.
Discussion
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Common themes?
Problem solving?
Thank You
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Stephen.lithgow@ggc.scot.nhs.uk