Changing practice to reduce
admissions for people with
dementia
Dr Afifa Qazi
Consultant Old Age Psychiatrist
Havering older people’s services
[email protected]
Evolution of older people’s services
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Institution to Care in the community
Geriatric services 1940s
Psycho-geriatric services 1960s
Day hospitals
Community mental health teams
Changing role of the consultant
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National Dementia Strategy
Improved community support services
Living well with dementia in care homes
New Ways of Working DOH 2005
improving relations with primary care and
community
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NICE Guidance for Dementia - support
people with dementia in the community as
far as possible
Components of the service
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Community Mental Health Team
Memory clinic / out-patient clinic
Home Treatment Team
Liaison service
Day hospital
In-patient ward
Dementia care
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Diagnosis
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Acute
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Follow-up
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Chronic
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Crisis management
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Preventative
Population
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Havering , borough with most older people
Office of National Statistics 2008
40,700 over 65yrs
3400 with dementia
30% (1100) of those in care homes
Three psychiatric teams covering roughly
the same catchment-areas
Very low admission rates
Inpatient admissions Havering
(04/09 to 03/10)
30
26
25
20
25
19
15
10
5
0
Admissions
Team A
Team B
Team C
Admissions for Team A
(04/09 to 03/10)
20
18
16
19
15
14
12
10
8
6
4
2
0
Total
Admissions
Functional
Disorders
Dementia
4
Average length of stay
89
90
80
73
70
60
50
40
30
29
20
10
0
Days
Team A
Team B
Team C
Bed usage
April 09 – March 10
2500
2314
1825
2000
1500
1000
551
500
0
Bed
days
Team A
Team B
Team C
Inpatient Admissions NELFT
per 10,000 population
50
50
45
40
37
35
30
25
20
15
10
5
0
30
29
25
21
16
19
29
Average length of stay - NELFT
89
90
80
73
70
60
50
37
40
30
20
10
0
29
40 41
40
42 39
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team 1
Bed Days
per 10,000 population
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team I
Bed Occupancy
per 10,000 population
16
14
12
10
8
6
4
2
0
Team A
Team B
Team C
Team D
Team E
Team F
Team G
Team H
Team I
RCPsych
Source of referrals
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G.P s
Elderly medicine and neurology
District nurses
Care homes
General practice
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Close working links with GPs/practice nurses,
consultant mobile number
Excellent secretarial support
Quick response (same day)
Talks at surgeries leading to improved quality of
referrals, improving GP confidence in managing
psychiatric disorders
GPs not good at detecting and managing
dementia ( “Forget me not” 2002 audit
commission)
Face to face discussions (eg referral for acute
confusion)
Care homes
(1/3rd of people with dementia)
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Close working links with homes &
consultant mobile number
Prompt response
Training sessions, talks
Regular “surgeries” at homes with
“problems”
Able to identify difficulties before reaching
crisis point
No admissions from care homes over last
2 yrs
CMHT
single point of access
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Weekly meetings, discussions
Joint visits
Close links
Home visits 5 days a week
Prompt response and consultant
mobile number encouraged to call
Out patient clinics
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Emergency slots for patients in a
crisis situation
Frequent follow ups for acutely
unwell patients (2-4 weekly)
Encourage patients to ring in case of
problems (provide contact sheet to
all ops with secretaries number)
Patients not falling within day
hospital or HTT
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Case 1 Mrs EE
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Case 2 Mrs ES
Key elements
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Access - support
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Training – development
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Liaising- providing the missing link
TEAM EFFORT
Conclusion
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Bed occupancy - <10% of RCPsych
recommended bed numbers
1/4 of beds of average NELFT consultants
per 10,000 population
Changing practice:
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reduces admissions
cost effective
popular with CMHT, care homes and GPs
adds to effects of home treatment services
takes time for full effects