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The aims of the Partnership -

The Sussex Dementia Partnership is a clinically-led collaboration between the health and social care commissioners and providers of Sussex involved in Dementia care. It aims to transform dementia services in line with the National Dementia Strategy (NDS) in order to improve the experience of people with dementia and their carers. Dementia is a significant and increasing financial burden in Sussex. There are different commissioning and provider arrangements for dementia across Brighton & Hove, East Sussex and West Sussex. Evidence suggests that working collaboratively across organisational and geographical boundaries to implement the dementia transformation programme with a QIPP focus could enable Sussex to meet future challenges against a backdrop of financial constraint, and this has led to the formation of the Partnership. The vision of the programme is to achieve improvements in the following areas:
  • The experience of people with dementia and their carers
  • Early diagnosis of dementia and access to information and support
  • Numbers of people treated (within existing resources) in order to meet significant demographic increases over the next 10 years
  • Improved care in the general hospitals, plus a reduction in inappropriate admissions and length of stay
  • Improved care in care homes
  • Access to dementia crisis support at home services
  • Reduced inappropriate use of anti-psychotic medication
  • Reduced unwarranted variation in services across Sussex
 

Outcomes

There has been significant progress in delivering the NDS. A full Memory Assessment Service with Dementia Advisors has started in West Sussex and procurement is also underway in the other localities meaning that full coverage will be achieved by April 2013. The quality of care in general hospitals has improved notably; Older People’s Mental Health Liaison services have been extended across Sussex and the innovation of a Dementia Shared Care Ward is being spread to other hospitals. All four acute trusts have developed Dementia Strategies and are making progress in delivering improvements in education, environment and person-centred care. A Sussex wide dementia acute audit has provided the system with valuable information about the dementia profile in the hospitals and preventative approaches to admission. In care homes, a Sussex-wide service has been developed to focus on medication review and non-pharmacological approaches to challenging behaviour. This has led to quality improvements and reductions in anti-psychotic prescribing. Achievements have also been made in dementia crisis support services at home. Finally, work is in progress to improve services for people with dementia at end of life, to increase carers’ support and to provide education for the system in relation to reducing anti-psychotic prescribing.  

Patient setting

In-patient   X Out-patient   X Community based   X
Mental health   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care   X
Planned care Mental health    X Long-term conditions   X End of life   X
 

Information, tools and techniques used

The National Dementia Strategy was published in February 2009 and there was widespread belief that the strategy could not be implemented effectively by individual organisations in isolation. The concept of a partnership approach was initiated by CEOs and senior clinicians within Sussex, with the Director of Social Care and Partnerships South East acting as a catalyst to bring the different parts of the system together. The principles of the Academy for Large Scale Change model were utilised, focusing on mobilising, spreading and sustaining change. Whole system modelling was undertaken to understand the impact of implementing the NDS on demand and resources.  

Geography

Across the local authorities of Brighton & Hove, West Sussex and East Sussex.  

Timescale

The Sussex Dementia Partnership was set up in January 2010, following initial meetings during 2009. A programme manager was jointly funded by NHS Sussex and a Delivery Board established. A two year independent evaluation of the Partnership will be completed in October 2012 and this will form part of a review of the future of the Partnership in the light of the transition to clinical commissioning.  

Contact details and further information

Contact Charlotte Clow, Sussex Dementia Partnership Email charlotte.clow@nhs.net [post_title] => Sussex Dementia Partnership [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => sussex-dementia-partnership [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:55:40 [post_modified_gmt] => 2013-01-16 14:55:40 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3402 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [1] => WP_Post Object ( [ID] => 3398 [post_author] => 8 [post_date] => 2013-01-16 14:47:29 [post_date_gmt] => 2013-01-16 14:47:29 [post_content] =>

The journey -

The Reablement programme helps patients or their carers to be experts in their own care and maintain independence for as long as possible.  By giving tailored solutions that don’t foster dependence and supporting people to remain in their own homes, it ultimately aims to reduce health inequalities and build a cost-effective service that meets demand. The programme takes a systems approach. This has meant taking a long hard look at the way that services are delivered and has led to fundamental changes in service provision, rather than simply ‘doing the wrong things righter’, as one programme manager put it. Listening to patients and collaborating across professional and organisational boundaries are both central to what makes the Reablement programme work. In Somerset, the PCT and the county council jointly reviewed all their services that might be termed ‘reablement’. They worked in partnership with private and voluntary sector organisations and the new CCG to deliver better, more coordinated services.  

Outcomes

In Somerset, the Reablement programme has led to an increase in collaboration across the healthcare sector and made significant changes in how patients are assessed and what services are provided. An example is a patient with a history of sciatic pain who had a fall. Previously, he would have been hospitalised, but his GP contacted the Reablement team, who quickly established that he would prefer to be at home. The team devised a personal support package that enabled him to gradually increase his mobility without being admitted to hospital. Ultimately, the programme has delivered a number of real gains in service quality, patient outcomes, productivity and staff motivation. This includes significant reductions in hospital readmissions and the cost of social care.  

Patient setting

In-patient   X Out-patient   X Community based   X
Mental health Chronic illness   X Cross-systems   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care    X
Planned care Mental health Long-term conditions    X End of life   X
 

Information, tools and techniques used

The programme used Vanguard Consulting’s change methodology for systems thinking.  

Geography

The programme was first piloted in the Taunton federation and is being rolled out more widely across the county.  

Timescale

The Somerset Reablement programme started in spring 2010 with a pilot in Taunton. From January 2012 Reablement was mainstreamed in Taunton and rolled out in another large federation in Somerset.  

Contact details

Ann Anderson ann.anderson@somersetccg.nhs.uk and Sue Glanfield Susan.glanfield@somerset.nhs.uk were both members of the project team.

[post_title] => Reablement programme, Somerset [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => reablement-programme-somerset [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:47:29 [post_modified_gmt] => 2013-01-16 14:47:29 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3398 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 3396 [post_author] => 8 [post_date] => 2013-01-16 14:44:05 [post_date_gmt] => 2013-01-16 14:44:05 [post_content] =>

The journey -

This programme established a new admissions unit, the Rapid Assessment & Consultant Evaluation (RACE) ward.  Here medical patients with geriatric needs (frailty, multiple co-morbidities, advanced age dementia) referred to hospital as emergencies, are assessed and cared for by a consultant-led multidisciplinary (MDT) team, including doctors, nurses, physiotherapists, occupational therapists and community support staff. All patients receive comprehensive geriatric assessment (CGA) within 24 hours of admission and there is a daily multidisciplinary meeting attended by the ward team and representatives from Poole Intermediate Care Service, Poole Social Services and Dorset Social Services to facilitate discharge planning. GPs can also refer patients to the daily emergency clinic held on the ward to access rapid diagnostics and CGA without admission to hospital. The aim of the unit is rapid comprehensive assessment of older patients with complex needs. This facilitates early supported discharge and avoids unnecessary hospital stays which can be detrimental to older patients. The trust benefits from a reduced length of stay for older patients with concomitant savings.  

Outcomes

Within 3 months of the establishment of the RACE ward marked improvements were recorded. Patient discharge within 48 hours increased from 20{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} to 40{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b}, and average length of stay decreased from 19 to 13 days. The quality of patient care also improved as a result of comprehensive geriatric assessment at the front door.  

Patient setting

In-patient   X Out-patient Community based
Mental health Chronic illness   X Cross-systems   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care    X
Planned care    X Mental health    X Long-term conditions    X End of life   X
 

Information, tools and techniques used

The original impetus for the change was managerial, but the change was driven bottom up: planned, led and implemented by clinicians.  

Geography

The change took place in Poole Hospital, Dorset.  

Timescale

The change took place in June 2010 and lasted 6 weeks from planning to implementation. Now fully embedded, the operation of the RACE ward has continued to develop and evolve.  

Contact details and further information

Prem Fade, Department Director: Prem.Fade@poole.nhs.uk [post_title] => Rapid Assessment & Consultant Evaluation (RACE) [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => rapid-assessment-consultant-evaluation-race [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:44:05 [post_modified_gmt] => 2013-01-16 14:44:05 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3396 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 3393 [post_author] => 8 [post_date] => 2013-01-16 14:35:00 [post_date_gmt] => 2013-01-16 14:35:00 [post_content] =>

The journey -

The aim of this programme was to implement an integrated plan for the care of the frail and elderly with the aim of reducing hospital admissions.  Many older people were finding it difficult to access the right services, so part of the aim was to simplify and co-ordinate care for this group of patients. The first steps were informal conversations among interested parties.  This led to the formation of a local strategic partnership spanning health and social care specialists.  The programme looked at all areas relevant to patients aged over 65, learning disabled and other vulnerable people.  These included dementia, end-of-life care, balance classes to reduce falls and ‘living well at home.’  

Outcomes

The programme is still ongoing, but there is some evidence of fewer hospital admissions in this age group.  Another benefit has been improved relationships between strategic partners and considerable learning in areas such as aligning finances, outcome measurements, assessment processes and the politics of organisational relationships.  

Patient setting

In-patient Out-patient Community based   X
Mental health   X Chronic illness   X Cross-systems   X
 

Clinical area

Staying healthy   X Maternity and newborn Children and young people Acute care
Planned care Mental health    X Long-term conditions    X End of life   X
 

Information, tools and techniques used

The programme started with informal networking among interested parties and progressed to a more formal local strategic partnership.  Specific change management tools were not used.  

Geography

Crawley area including Crawley Borough Council; Crawley CCG; West Sussex County Council; Sussex Partnership Foundation Trust and voluntary groups.  

Timescale

The programme is still ongoing.  

Contact details and further information

Dr Amit Bhargava, GP Principal, Southgate Medical Group, Crawley: amit.bhargava@btopenworld.com [post_title] => Integrated care of the frail and elderly [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => integrated-care-of-the-frail-and-elderly [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:37:39 [post_modified_gmt] => 2013-01-16 14:37:39 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3393 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 3327 [post_author] => 8 [post_date] => 2013-01-02 15:54:41 [post_date_gmt] => 2013-01-02 15:54:41 [post_content] =>

The journey -

The community response and reablement service programme, undertaken by Bracknell and Ascot CCG commissioners jointly with Bracknell Forest Council, pursued an alternative to hospital-based intermediate care.  It worked across health and social care in areas where the lead commissioner for the service is the local authority via a Section 75 agreement. The core purpose of the programme was to set up a joint service for the provision of bed based reablement. Some beds in a community hospital were decommissioned and a formal application was made by the clinical commissioning group (CCG) to invest in more local bedded reablement in a social care setting.  The change happened concurrently with a continued shift in patient flow.  Previously almost all acute non-elective admissions to hospital were to one district general hospital (DGH).  Now admissions are split between 3 neighbouring acute hospital trusts.

Outcomes

A number of outcomes have been recorded in relation to the performance of the health and social care system.  These include minimal delayed transfers of care and an encouraging rise in admissions directly from home via GP referral.  People using the service report high satisfaction with the service.

Patient setting

In-patient Out-patient Community based
Mental health Chronic illness Cross-systems   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care   X
Planned care Mental health Long-term conditions   X End of life  X
 

Information, tools and techniques used

No specific change management methodology was used.  Instead the programme took a pragmatic approach to engaging with stakeholders with a common purpose.

Geography

The programme involved local community health services provided by Berkshire Healthcare NHS FT, the CCG for Bracknell Forest and Ascot; Bracknell Forest local authority and three acute hospitals.

Timescale

The programme started in July 2012 and is still ongoing.

Contact details and further information

Mira Haynes, Chief Officer: Older People and Long Term Conditions, Bracknell Forest Council -  mira.haynes@bracknell-forest.gov.uk

Mary Purnell, Assistant Director of Commissioning, NHS Berkshire East - Mary.purnell@berkshire.nhs.uk

[post_title] => Community response and reablement service (Bracknell Forest) [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => community-response-and-reablement-service-bracknell-forest [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:16:03 [post_modified_gmt] => 2013-01-16 14:16:03 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3327 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 5 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 3402 [post_author] => 8 [post_date] => 2013-01-16 14:55:40 [post_date_gmt] => 2013-01-16 14:55:40 [post_content] =>

The aims of the Partnership -

The Sussex Dementia Partnership is a clinically-led collaboration between the health and social care commissioners and providers of Sussex involved in Dementia care. It aims to transform dementia services in line with the National Dementia Strategy (NDS) in order to improve the experience of people with dementia and their carers. Dementia is a significant and increasing financial burden in Sussex. There are different commissioning and provider arrangements for dementia across Brighton & Hove, East Sussex and West Sussex. Evidence suggests that working collaboratively across organisational and geographical boundaries to implement the dementia transformation programme with a QIPP focus could enable Sussex to meet future challenges against a backdrop of financial constraint, and this has led to the formation of the Partnership. The vision of the programme is to achieve improvements in the following areas:
  • The experience of people with dementia and their carers
  • Early diagnosis of dementia and access to information and support
  • Numbers of people treated (within existing resources) in order to meet significant demographic increases over the next 10 years
  • Improved care in the general hospitals, plus a reduction in inappropriate admissions and length of stay
  • Improved care in care homes
  • Access to dementia crisis support at home services
  • Reduced inappropriate use of anti-psychotic medication
  • Reduced unwarranted variation in services across Sussex
 

Outcomes

There has been significant progress in delivering the NDS. A full Memory Assessment Service with Dementia Advisors has started in West Sussex and procurement is also underway in the other localities meaning that full coverage will be achieved by April 2013. The quality of care in general hospitals has improved notably; Older People’s Mental Health Liaison services have been extended across Sussex and the innovation of a Dementia Shared Care Ward is being spread to other hospitals. All four acute trusts have developed Dementia Strategies and are making progress in delivering improvements in education, environment and person-centred care. A Sussex wide dementia acute audit has provided the system with valuable information about the dementia profile in the hospitals and preventative approaches to admission. In care homes, a Sussex-wide service has been developed to focus on medication review and non-pharmacological approaches to challenging behaviour. This has led to quality improvements and reductions in anti-psychotic prescribing. Achievements have also been made in dementia crisis support services at home. Finally, work is in progress to improve services for people with dementia at end of life, to increase carers’ support and to provide education for the system in relation to reducing anti-psychotic prescribing.  

Patient setting

In-patient   X Out-patient   X Community based   X
Mental health   X
 

Clinical area

Staying healthy Maternity and newborn Children and young people Acute care   X
Planned care Mental health    X Long-term conditions   X End of life   X
 

Information, tools and techniques used

The National Dementia Strategy was published in February 2009 and there was widespread belief that the strategy could not be implemented effectively by individual organisations in isolation. The concept of a partnership approach was initiated by CEOs and senior clinicians within Sussex, with the Director of Social Care and Partnerships South East acting as a catalyst to bring the different parts of the system together. The principles of the Academy for Large Scale Change model were utilised, focusing on mobilising, spreading and sustaining change. Whole system modelling was undertaken to understand the impact of implementing the NDS on demand and resources.  

Geography

Across the local authorities of Brighton & Hove, West Sussex and East Sussex.  

Timescale

The Sussex Dementia Partnership was set up in January 2010, following initial meetings during 2009. A programme manager was jointly funded by NHS Sussex and a Delivery Board established. A two year independent evaluation of the Partnership will be completed in October 2012 and this will form part of a review of the future of the Partnership in the light of the transition to clinical commissioning.  

Contact details and further information

Contact Charlotte Clow, Sussex Dementia Partnership Email charlotte.clow@nhs.net [post_title] => Sussex Dementia Partnership [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => sussex-dementia-partnership [to_ping] => [pinged] => [post_modified] => 2013-01-16 14:55:40 [post_modified_gmt] => 2013-01-16 14:55:40 [post_content_filtered] => [post_parent] => 0 [guid] => http://clients.electricstudio.co.uk/tvhiec/wpcms/?post_type=improvement-science&p=3402 [menu_order] => 0 [post_type] => improvement-science [post_mime_type] => [comment_count] => 0 [filter] => raw ) [comment_count] => 0 [current_comment] => -1 [found_posts] => 10 [max_num_pages] => 2 [max_num_comment_pages] => 0 [is_single] => [is_preview] => [is_page] => [is_archive] => 1 [is_date] => [is_year] => [is_month] => [is_day] => [is_time] => [is_author] => [is_category] => [is_tag] => [is_tax] => 1 [is_search] => [is_feed] => [is_comment_feed] => [is_trackback] => [is_home] => [is_privacy_policy] => [is_404] => [is_embed] => [is_paged] => [is_admin] => [is_attachment] => [is_singular] => [is_robots] => [is_favicon] => [is_posts_page] => [is_post_type_archive] => [query_vars_hash:WP_Query:private] => 4ecb2399e1ace483aad0ae75da154791 [query_vars_changed:WP_Query:private] => [thumbnails_cached] => [stopwords:WP_Query:private] => [compat_fields:WP_Query:private] => Array ( [0] => query_vars_hash [1] => query_vars_changed ) [compat_methods:WP_Query:private] => Array ( [0] => init_query_flags [1] => parse_tax_query ) ) [1] => derp )

Category: End of life

Sussex Dementia Partnership

The aims of the Partnership – The Sussex Dementia Partnership is a clinically-led collaboration between the health and social care commissioners and providers of Sussex involved in Dementia care. It aims to transform dementia services in line with the National Dementia Strategy (NDS) in order to improve the experience of people with dementia and their […]

Posted on Jan 16th Cat: , , , , , , , , Comments: Comments are off for this post

Reablement programme, Somerset

The journey – The Reablement programme helps patients or their carers to be experts in their own care and maintain independence for as long as possible.  By giving tailored solutions that don’t foster dependence and supporting people to remain in their own homes, it ultimately aims to reduce health inequalities and build a cost-effective service […]

Posted on Jan 16th Cat: , , , , , , , , Comments: Comments are off for this post

Rapid Assessment & Consultant Evaluation (RACE)

The journey – This programme established a new admissions unit, the Rapid Assessment & Consultant Evaluation (RACE) ward.  Here medical patients with geriatric needs (frailty, multiple co-morbidities, advanced age dementia) referred to hospital as emergencies, are assessed and cared for by a consultant-led multidisciplinary (MDT) team, including doctors, nurses, physiotherapists, occupational therapists and community support […]

Posted on Jan 16th Cat: , , , , , , , , Comments: Comments are off for this post

Integrated care of the frail and elderly

The journey – The aim of this programme was to implement an integrated plan for the care of the frail and elderly with the aim of reducing hospital admissions.  Many older people were finding it difficult to access the right services, so part of the aim was to simplify and co-ordinate care for this group […]

Posted on Jan 16th Cat: , , , , , , , , Tags: Comments: Comments are off for this post

Community response and reablement service (Bracknell Forest)

The journey – The community response and reablement service programme, undertaken by Bracknell and Ascot CCG commissioners jointly with Bracknell Forest Council, pursued an alternative to hospital-based intermediate care.  It worked across health and social care in areas where the lead commissioner for the service is the local authority via a Section 75 agreement. The […]

Posted on Jan 2nd Cat: , , , , , , , Tags: Comments: Comments are off for this post