Post Diagnosis Support. Emerging Themes in Glasgow Stephen Lithgow Dementia Support and Development Lead. GG&C NHS. 7th March 2014. Webex Objectives      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      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     ‘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.  Glasgow South Sector Glasgow South Sector.       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.      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.      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.     Monthly data returns started. Personal plan developed. Started using an outcomes approach. Raised £371,000. Piloted supported self management. Driver Diagram      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.  Person Centred Care.     Outcomes and NHS staff. NES and SSSC training. Personal Plan. Using Outcomes. Quantitative and qualitative recording. Partnership Governance      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     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.       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.        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       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.     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       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     Example. Done from ‘scratch’. Outcomes difficult. Staff feel there is repetition. Issue: Personal Plan.       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.                   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       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.       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      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        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       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   Common themes? Problem solving? Thank You  Stephen.lithgow@ggc.scot.nhs.uk