PREVENTING ADMISSION TO HOSPITAL AND RESIDENTIAL CARE FOR PEOPLE WITH DEMENTIA

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PREVENTING ADMISSION TO HOSPITAL AND RESIDENTIAL
CARE FOR PEOPLE WITH DEMENTIA

• David Shinegold
• Social Care Consultant
• Skills for Care Co-ordinator - Berkshire
• Tel [phone]

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SKILLS FOR CARENew Type of Worker Initiative

• The drivers for new social care roles include
• User focused service design with staff able
  to provide more generic individualised services
• Improving strategic human resource and
  operational management of the workforce
• A reduction in the actual number of staff
  required to deliver services to a person using
  them
• A more skilled and independent high quality
  workforce able to manage services at the point of
  delivery
• A blurring of some long established
  demarcations between job roles.

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The drivers particular to Bracknell Forest
Borough Council were to make an impact on the
following performance indicators

• To increase the number of older people helped to
  live at home
• To decrease the number of admissions of people
  over 65 years to residential and nursing care
• To decrease the number of emergency admissions of
  older people to hospital

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The Project Management Team consisted of
stakeholders whose job roles contributed to the
successful operation of the project
BFBC Head of Long Term Care Overall management of the project
BFBC Team Manager (Home Support) Co-ordinate development of the project
BFBC Home Support Manager Manage the delivery of the service
BFBC Care Co-ordinator Advise on referrals and levels of care
BHC Trust Community Psychiatric Nurse Assessment of referrals
Bracknell Alzheimers Society - chair Represent service users and undertake research
BHC Trust Psychiatrist Advise on medical practice
BFBC Human Resources Manager Facilitate changes to the terms and conditions of Support Workers
BFBC Service Commissioner Facilitate changes to the way services were commissioned
Skills for Care Contractor Monitor the project outcomes and disseminate information
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In order to provide a cost effective domiciliary
care service enabling people with dementia to
remain in the community, the following areas were
considered and addressed

• The nature of the support that would be available
  to service users
• The structure within which the service would be
  provided and managed
• The terms and conditions under which support
  workers would be employed
• The training that would be available to support
  workers

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As the project developed, it became clear that
there was a considerable impact on

• The relative-carers of service users
• Staff sickness and retention levels
• Implications for inter-agency collaboration
• The involvement of project stakeholders
• In-patient levels in the local hospital dementia
  ward

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The nature of the support that would be
available to service users

• Assessments would involve and represent the views
  of service users and relative-carers
• An Outcome Based service would be provided based
  on Care Plans that focussed on outcomes rather
  than service levels
• Focus on improving and maintaining the
  relationship between the service user and their
  relative-carer
• A service user would receive consistent support
  from one main Support Worker
• Social Policy Research Unit at the University of
  York

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Examples of Outcomes for the service user which
the Care Plan may include

• Increased physical abilities
• Increased confidence or skills
• Improved mental health
• More social opportunities
• Have finances in order
• Essential physical needs met
• Quality of life maintained
• Cleaner/safer environment
• Changes in behaviour
• Risks reduced or removed

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The structure within which the service would be
provided and managed required Support Workers to
have additional responsibilities to those
normally undertaken by Domiciliary Care Workers
which included

• Encourage service users to regain lost skills
• Encourage participation in and transport service
  users to a variety of activities including
  shopping, day centres, outings, hospital
  appointments etc
• Offer personal support, advice and encouragement
  to service users and relative-carers
• Help service users maintain contact with family
  and friends
• Provide practical support and intimate personal
  care as well as household tasks to relieve some
  of the work carried out by relative-carers

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Further tasks were required which were to raise
the professional status of Support Workers

• Undertake specialist tasks under the supervision
  of professionally qualified team members
• Record information on Observation Sheets
• Submit written and verbal reports to the
  Community Psychiatric Nurse
• Take part in monitoring, reviewing, decision
  making and care planning

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This led to modifying the Person Specification
for Support Workers to include

• Able to use initiative and deal with emergencies
• Organisational skills
• Recording and reporting skills
• Able to undertake and benefit from specialised
  training
• Stable
• Self reliant
• Stress tolerant

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Raising the professional status of Support
Workers was also achieved by

• Employing workers on a salaried rather than an
  hourly paid basis
• Employing workers to work flexible hours at their
  own discretion
• Giving workers the autonomy to respond to
  situations as they found them
• Providing professional supervision both
  individually and as a team
• Providing professional training in dementia (UCL)
• Provide a structure enabling workers to
  communicate with one another, cover for each
  others absences and maintain continuity of care
• Provide opportunities to achieve NVQ at level 3
  and above (compared with the normal expectation
  of domiciliary care workers achieving NVQ level
  2).

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Referrals to the Project Team took account of the
following criteria

• Diagnosis of dementia
• Known to local Mental Health team
• At risk of the home situation breaking down
• Reluctant or resistant to accepting traditional
  domiciliary care services

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Referrals to the Dementia TeamMarch 2005
March 2006 13 months
Total number of Service Users Discharged early from hospital Prevented from hospital admission Prevented from admission to residential/nursing care Referrals not linked to imminent admission
33 1 3 15 14
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The range of needs identified included

• Dementia and alcohol abuse
• Forgetting to take medication
• Withdrawal of carer-relative due to change in
  work pattern
• Unable to maintain personal care/clean
  environment/ suitable diet/financial control
• Relative-carer unable to cope with increasing
  demands due to dementia
• Challenging behaviour due to dementia
• Weight loss

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Number of Hours Support Received per Week from
Dementia Team
Service User Groups (Nos.) Max. No. of hours/wk support received Min. No. of hours/wk support received Average No. of hours/wk support received
Prevented from admission to hospital care (4) (No. of weeks 100) 17.5 2.5 9.25
Prevented from admission to residential or nursing care (15) (No. of weeks 364) 12 3.5 7.55
Referrals not linked to imminent admission (14) 8.25 1.5 4.44
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Financial Savings Over 13 monthsHospital Care
No. of Service Users No. of Weeks Cost per week in hospital Total Cost In hospital Cost per hour Dementia Team Total Cost of Dementia Team Average 9.25 hrs/wk Savings
4 100 1,575 157,500 32.42 29,988 127,511
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Financial Savings Over 13 monthsResidential/Nursi
ng Home Care
No. of Service Users No. of weeks Cost per week in Res. Or Nursing Home Care Total Cost in Res. or Nursing Home Cost per hour Dementia Team Total Cost of Dementia Team Average 7.55 hrs per week Savings
15 364 450 163,800 32.42 89,096 74,704
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Outcomes Significant to Service Users

• The areas of the service provided by the
  dementia team which elicited the highest
  satisfaction ratings were
• Support Workers took account of my views
• Improvements in my emotional and mental health
• The help I receive fits in with my life and
  routine
• My relationship with my relative-carer has
  improved
• I feel that I have been treated with respect

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Outcomes Significant to Relative-Carers

• I feel treated with respect
• The Support Worker takes account of my views when
  deciding what help to provide
• The Support Worker understands my individual
  needs and circumstances very well
• The Support Worker was very helpful in providing
  information about other services available
• 57 of relative-carers reported improvements in
  their general health
• 64 of relative-carers reported improvements in
  their emotional and mental health
• 85 of relative-carers felt that the help they
  received fitted in with their life and routine

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A Selection of Comments from the Support Workers

• More time not rushing with the service user
• Feel you have achieved things
• Building relationship with service user and
  relative-carer
• Intensive work
• Im knackered!
• Good team rapport and trust
• Communicate with each other, management and
  relatives
• Knowledge of service user gives you more
  satisfaction
• Empowering encouraging service user to regain
  skills in everyday activities
• Make phone calls in the evening to relatives
• Good understanding of team-mates work

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MAJOR OUTCOMES AFTER 3 YEARS

• Hospital waiting list reduced to zero
• Dementia ward is now only 50 full
• All of the original support workers remain in
  post
• Only 2 weeks of genuine sick leave taken
• The Dementia Team is now a mainstream service and
  is to be tripled in size
• This model of service is to be extended to other
  areas e.g. people with long term conditions
• The Dementia Team won the Skills for Care
  Accolades in 2007