Enhanced care home outcomes in Oxfordshire

The aim of this project is to improve the quality of service for people living with dementia by integrating the established care home support service to create a new mental health in-reach service.

The new service will:

  • Eliminate inconsistent quality of service in care homes.
  • Provide holistic care (physical and mental health) to people with dementia in care homes
  • Reduce admission rates and Delayed Transfer of Care

The majority (60{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}+) of people in Oxfordshire care homes have a dementia and many of these also have co-existing physical or mental health needs. Managing this range of complex needs can be difficult for the largely untrained workforce in care homes who can struggle to bring together the physical and the mental aspects of care.

It is believed that this contributes to inappropriate admissions to care homes when people could continue to live in their own community, to high admission rates to hospital and to high levels of Delayed Transfer of Care (DTOC).

Three teams, Care Home Support Service (Falls prevention in-reach), PCT Pharmacy Liaison and Community Mental Health Teams provide in-reach services to care homes but operate separately have separate referral points and respond only for specific elements of need. They also have different training which is not linked and without a common foundation. Consequently there are gaps and inconsistency in quality of the services.

Learning from elsewhere

A service model of mental health in-reach delivered by a single team has been successful in the North East of England. This integrates practitioners in the existing 3 services and trains them to support both care homes and the hospital services. This more holistic service means people with dementia and complex needs receive the more appropriate and personalised care planning and services.

Deliverables

  • Development of new roles to provide enhanced mental health expertise within the existing Care Home Support Service team
  • Organisational change to bring together the new single team
  • Training in the“ Newcastle Model” of dementia in the care home support service
  • Production of protocols for new team operation, patient assessment and interventions which are delivered directly in care homes or when transfer between from one service to another is considered
  • Adoption of the “Newcastle Model” of dementia  care service working with all care homes in the county with a single (integrated) team providing holistic care and a single point of access
  • Promotion of new service to GPs
  • Establishment of liaison protocols with General and Community Hospitals

 Anticipated outcomes

  • Improved quality of service measured through routine service evaluation questionnaires with care homes, families and those primary and secondary care providers who have contact with the service.
  • Greater numbers of people with a confirmed diagnosis and appropriate care plan measured through CCG QOF data showing numbers of people in care homes with a diagnosis.
  • Improved well-being for people with dementia measured through the use of Dementia Care Mapping (part of another project). Also through data collected in the implemented integrated service model e.g. reduction in scores on CMAI (Cohen Mansfield Agitation Inventory) after intervention, increase in well- being and reduction of ill being scores (on Well and Ill being profile) used as part of service delivery model evidenced by care plan audit.
  • Fewer crisis admissions to hospital and speedier return to independent living measured through planned and crisis admissions recorded from care homes.
  • Better family / carer satisfaction.

 Progress update

This innovative project brings together physical and mental health to improve the quality of life for people with dementia. An evidenced based model will be used to deliver interventions and staff will be trained to deliver this to start implementing early in 2014. This is the first such service in the country.

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