Coordinating evidence-based
therapy at a national level: a
case study in post-diagnostic
dementia care
Royal College of Occupational Therapists
Annual Conference 2017
Wendy Chambers, Alison McKean, Lynda Forrest, Elaine Hunter and
Duncan Pentland
More info: [email protected]
#OTHBMR
@elaineahpmh
#Connectingpeople
@wendyAHPDem
@AliAHPDem
@DuncsOT
Seminar aims
• Brief overview of Home Based Memory Rehab
• Detail methods used to promote national
implementation
• Understand and explore possible challenges
• Increase awareness of potential solutions
• Consider strategies for supporting coordinated
implementation of occupational therapy
programmes
• Debate how to incorporate occupational therapy
practice into national government strategies
Design
Understand
Keeping the
person at the
centre
Implementation
Evaluation
Embed &
Sustain
Relational approaches
Technical approaches
Share learning
www.ihub.scot
Understand
• National strategies4,5 around
improved post diagnostic
support (PDS) in dementia
• National scoping exercise
undertaken (2014) to explore
AHP contribution to PDS (OT
n=75)
Supported self
management
approaches
Environmental
modification
Home Based
Memory
Rehabilitation
Programme
OT role in
Post
Diagnostic
Support
PDS support
groups
Memory
techniques/
skills/
management
Understand
• Occupational therapists participating in the
national scoping exercise:
– Recognised that people with dementia were not
receiving access to their services at the right time
– Reported they could be doing more in the area of
Post Diagnostic Support in Dementia
– Identified Home Based Memory Rehabilitation as
intervention they would like to take forward as
best practice
Design
Understand
Keeping the
person at the
centre
Implementation
Evaluation
Embed &
Sustain
Relational approaches
Technical approaches
Share learning
www.ihub.scot
Design
• Evidence-based early intervention
in dementia3
• Developed & pilot-RCT completed
by Mary McGrath, specialist
occupational therapist1
• 2013/15 Tested & HBMR resource
pack created in Dumfries and
Galloway, Scotland
Design
• Evidence of strategies to compensate for
memory difficulties being used two years
following completion of HBMR
Mean no. strategies used
6
5
4
3
2
1
0
Pre-therapy
End of
therapy
3 months posttherapy
1 year posttherapy
Home-Based Memory Rehab
• Based on cognitive rehabilitation theory and
techniques
• Key is to compensate for memory difficulties via:
– Environmental Adaptation
– Use of external memory aids
– Use of internal memory strategies
• Delivered over 4 and up to 6 sessions
• Structured and repetitive to encourage new learned
behaviours in early stages of dementia
• Embeds coping strategies as habits and routines
– More likely to be remembered and can be relied on
as/when memory difficulties progress
Home-Based Memory Rehab
1.
2.
3.
4.
5.
6.
Your priorities
What people have told you
Something you have to do
Coping in social situations
Keeping your brain healthy
Your bearings
Person
centred
Occupation
focussed
Clinically
reasoned
Design
Understand
Keeping the
person at the
centre
Implementation
Evaluation
Embed &
Sustain
Relational approaches
Technical approaches
Share learning
www.ihub.scot
Promoting national implementation
2012
COT Factsheet about McGrath and Passmore’s pilot study
2013
Developing resources
NHS DG initial pilot and adaptation to local context
2014
National Scoping Project
1st National Workshop
2nd National Workshop
HBMR Features in Connecting People,
Connecting Support as part of Scotland’s
National Dementia Strategy 3
Pilot evaluation wins Scottish national
Dementia Award
2015
NHS DG approached
to share HBMR
2016
QMUAlzheimer
Scotland
partnership
2017
Promoting national implementation
• Conversations, communication and leadership
Strategic
– National Alzheimer Scotland Dementia Consultant
– Alzheimer Scotland AHP Dementia Forum
– Alzheimer Scotland AHP Project Lead in Post
Diagnostic Support in Dementia
– National scoping
Local exercise Individual
– Occupational Therapy dementia working group
(Scotland)
• Scotland wide monthly teleconferences
Strategic
Enablers for change
• Awareness of and response to national policy
– 3rd National Dementia Strategy for Scotland about
to be published
– Connecting people, connecting support
– The Active & Independent Living Programme
(AILP) in Scotland
• Increasing the role of OT in early intervention
and post diagnostic support
• Recommendations to strengthen partnership
working between AHP Associate Directors and
AHP leaders with Alzheimer Scotland
• Linking with AHP directors for each board
– Nominate lead clinicians from each area
Strategic
– Agree roles and responsibilities
– Information to make choice to participate
• Local project charter (based on national exemplar
and drivers)
• Stakeholder analysis
Local
Individual
• Communication from clinicians up to director
level
• Space and voice to discuss local needs at national
level
• Monthly teleconferences among leads
HBMR offered
HBMR not currently offered
Status of HBMR provision by Scottish
regions
% population >30 in areas offering
HBMR
6
HBMR offered
In discussion
94
• Bottom up – therapists choosing to participate
• Knowledge and skills
Strategic
– Visits and demonstrations from expert clinician
– Webex video
– Promoting Excellence Framework (NES) – enhanced
level
– Annual national
workshops Individual
Local
• Access to NHS D&G team for advice and
experience
• Access to online ‘always open’ peer support
• Access to academic advice
Understanding & exploring challenges
• Local variation and challenges
– Referral pathways
– Capacity
– Evaluation practices
– IT variation
– Branding, ownership
– Direct resource costs
– Time pressures in clinical practice
Design
Understand
Keeping the
person at the
centre
Implementation
Evaluation
Embed &
Sustain
Relational approaches
Technical approaches
Share learning
www.ihub.scot
Evaluation practices
• All interventions are theories incarnate
• Complex interventions reflect many causal
assumptions2
• Logic model shows key components and
relationships during an intervention
• Informs relevant evaluation plans
Cognitive rehab
Cognitive
stimulation
Compensatory
Restorative
Preserved implicit memory =
ability to learn new & retain skills
Neuroplasticity = improvement in
specific cognitive functions
Skill learning focused on
meaningful occupations
Effects on cognitive function
generalise to occupational
performance
Skill acquisition,
retention
Cognitive function,
performance
Occupational
performance
Quality of life
Prerequisites
• Psychometrically sound for a early-mod
dementia population
• Free to use
• Useable as outcome measure
• Clinically useful
• Clinically operable (not burdensome)
• Score-able in several ways (clinician, PLWD,
proxy)
Cognitive function,
performance
ACEIII
ADAS-COG
3MS
Minicog
MMSE
GPCOG
MOCA
Everyday memory
problems
Occupational
performance
Skill acquisition,
retention
Quality of life
Bristol ADL Scale Bayer ADL
Katz Index
FIM
Barthel Index
AUSTOMS
Lawton Brody
PSMS
& IADL scales
HBMR strategy checklist
EQ5D
QUALIDEM
QOL_AD
DemQol
DQOL
QUALID
AQOL-8D
Quality of
therapeutic
interaction
Implementation
fidelity
Reach
Enhances /inhibits
HBMR process
Mode, frequency,
interval
Proportion of
appropriate PLWD
completing
Practical
applicability of
HBMR
Feasibility
Estimation of PDS
Identification of
subgroups
IT infrastructure
•
•
•
•
•
•
Uniform data recording
Excel based
Prebuilt service monitoring equations
Individual outcomes
Group outcomes calculations
Linked to review points
Still learning
•
•
•
•
•
•
Quoted administration times inaccurate
Reframe ideas about ‘difficult questions’
Streamline to minimum valuable battery
Translating QOL to HUI scores
Appropriate review points
Integrating/contributing to international
standards sets
Design
Understand
Keeping the
person at the
centre
Implementation
Evaluation
Embed &
Sustain
Relational approaches
Technical approaches
Share learning
www.ihub.scot
Strategic
• Updating, refreshing resources to fit all areas
• Continuing dialogue and problem solving
support
Local
Individual
• Background briefing notes
• Testing and decision making for evaluation
battery
Strategic
• Linking with LA/IJB colleagues
• Fitting provision within wider health systems to
ensure timely access in the PDS phase
Local
Individual
• Local evaluation and data-driven business
cases
• Work through improvement cycles
Strategic
• Expanding the evidence base (focus on wider
outcomes)
• Scotland’s National Dementia Strategy 3 (2017Local
Individual
2021)...Connecting People Connecting Support
• Undergraduate education
Sharing
• #OTHBMR
• #Connectingpeople
• RCOT Value of OT
• Let’s Talk About Dementia Blog
– alzscot.org/talking_dementia
• AILP Community of Practice (Dementia work-streams)
hosted on NHS Knowledge Network
– knowledge.scot.nhs.uk/ahpcommunity/ailip-priorityworkstreams/dementia.aspx
• More info – [email protected]
#OTHBMR #Connectingpeople
[email protected]
References
1.
2.
3.
4.
5.
6.
McGrath M and Passmore P (2009) Home-based memory
rehabilitation programme for persons with mild dementia. Irish
Journal of Medical Science. 178 (Suppl 8), S330
Moore et al (2015) Process evaluation of complex interventions:
Medical Research Council guidance, BMJ. 350:h1258
College of Occupational Therapists (2012) Evidence Fact Sheet:
Occupational therapists help those with dementia and their
carers. [rcot.co.uk/about-occupational-therapy/ot-evidencefactsheets]
Scottish Government (2010) Scotland’s National Dementia
Strategy.
Scottish Government (2017) Allied health professions co-creating
well-being with the people in Scotland. The Active and
Independent Living Programme in Scotland
Promoting Excellence Framework:
[knowledge.scot.nhs.uk/home/portals-and-topics/dementiapromoting-excellence/framework]