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The importance of community hospitals for dementia care


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The talk I will give on May 13th 2016 for the Annual Conference of the Community Hospitals Association. This event will be held in Bristol.

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The importance of community hospitals for dementia care

  1. 1. Community Hospitals Association Challenging Times Improving the experience of dementia through community hosptials Friday 13 May 2016 : 1.50 pm Bristol Marriott Royal Hotel, College Green Bristol Dr Shibley Rahman MA PhD MRCP(UK) MBA LLM Fellow of the England Centre for Practice Development o
  2. 2. About 800,000 living in the UK with dementia. Dementia is an umbrella term, covering more than 100 conditions. Progressive – no longlasting symptomatic treatment as yet. Policy aimed @ living better.
  3. 3. • Goals should be SMART – specific, measurable, achievable, realistic and time- oriented.
  4. 4. Impact of community services (King’s Fund 2014) The main steps identified are: • reduce complexity of services • wrap services around primary care • build multidisciplinary teams for people with complex needs, including social care, mental health and other services • support these teams with specialist medical input and redesigned approaches to consultant services – particularly for older people and those with chronic conditions • create services that offer an alternative to hospital stay • build an infrastructure to support the model based on these components including much better ways to measure and pay for services • develop the capability to harness the power of the wider community.
  5. 5. • Landscape of some services • English dementia strategy • Difference between community and centralised large hospitals • Learning from the acute hospital experience • Dementia friendly environments including ward settings • Specialist nurses and palliative care • Carers • Antipsychotics • Rights, enablement and rehabilitation
  6. 6. Small et al (2009) Post-acute rehabilitation care for older people in community hospitals – Philosophies of care and patients’ and caregivers’ reported experiences: A qualitative study. Disability and Rehabilitation, 31: 1862-1872.
  7. 7. Acute hospitals • Individuals with dementia who are in hospital can be greatly distressed by unfamiliar environments. • This might be a combination of cognitive difficulties and poor environments. • Prolonged hospital stays can lead to exposure of hazards including risk of falling or infections, for example.
  8. 8. National Audit of Dementia Skilling up the workforce • The 2nd round report highlighted that approximately 75% of hospitals now provide dementia awareness training to nurses. • Almost 50% are still failing provide demenrtia awareness training as part of induction. • This report finding suggests that further improvement is needed to provide better, more consistent staff training.
  9. 9. Harwood, 2012 • Forty per cent of acute general medical admissions over the age of 70 have dementia. • Cognitive impairment is evident in 60% of patients on acute geriatric medical wards, and in 55% of patients with hip fracture. • Overall, 25% of hospital beds accommodate someone with dementia
  10. 10. Harwood, 2012 “Family members and carers of people with dementia are frequently dissatisfied with their experience of hospital care, including staff not recognising or understanding dementia, lack of activity and social interaction, inadequate involvement in decision making and perceived lack of dignity and respect.”
  11. 11. Guardian (June 2014)
  12. 12. Guardian (June 2014)
  13. 13. Guardian (May 2014)
  14. 14. Delayed/inappropriate discharges (NHS Confederation, 2010) “Dementia is a predictor of a higher probability of inappropriate or delayed discharge. The opportunities of improvement through better discharge are significant. Reviewing the process and auditing readmissions associated with dementia are an important part of ensuring high performance in this area.”
  15. 15. Duchenko and Wood (2015) “Hippocampus”
  16. 16. Priorities of “dementia friendly hospitals” from Dementia Action Alliance • The environment in which care is given • The knowledge, skills and attitudes of the workforce • The ability to identify and assess cognitive impairment • The ability to support people with dementia to be discharged back home • The use of a person centered care plan which involves families and carers.
  17. 17. Wayfinding techniques • Accent colours • Artworks • Identification of bays, beds and social spaces • Signage – pictures and text
  18. 18. Orientation techniques • Artworks that reflect the seasons • Calendars • Large face clocks • Natural light • Outside spaces • Photographs of local scenes • Signs denoting ward and hospital name • Views of nature • Visible staff
  19. 19. Enhancing health environments (King’s Fund)
  20. 20. Mitchell (2016) “Doll therapy”
  21. 21. Rahman (2014)
  22. 22. Rahman and Dening (2016) Caring for a person with dementia affects the health and wellbeing of family carers. In the UK, government policy has increasingly highlighted the need to improve the lives of these carers and the current approach is for them to have access to a range of psychosocial and practical support. However, support available to carers is too often fragmented and inadequate.
  23. 23. It is impossible to deliver person-centred care unless you treat staff in a person-centred way.
  24. 24. Rahman and Dening (2016)
  25. 25. Rahman and Dening (2016)
  26. 26. Carers Trust/RCN (2015) “Triangle of care”
  27. 27. Rahman and Dening (2016) Palliative care is offered to improve quality of life, and there is growing evidence that an early palliative care approach benefits people with any type of chronic life-limiting illness (Beernaert et al, 2015), including dementia. It can improve their quality of life and that of their families by preventing or relieving suffering through early identification, assessment and treatment of pain and other poblems (World Health Organization, 2011).
  28. 28. Oliver (2016) “As many as 40% of hospital patients over 75 have dementia. It travels with them, although they’re generally admitted for other primary reasons. They’re more likely to die in hospital and to experience decompensation, depersonalisation, and harms.”
  29. 29. Oliver (2016) “We soon forget how far we’ve come and the importance of celebrating success, no matter who helped to start or tend the fire.”
  30. 30. Principle 1: Staff who are skilled and have time to care Principle 2: Partnership working with carers Principle 3: Assessment and early identification of dementia Principle 4: Care plans which are person centred and individual Principle 5: Environments that are dementia friendly
  31. 31. “Dementia champions”
  32. 32. Examples Northern Devon Healthcare Trust (NDHT) has joined national initiative John’s Campaign. It has been launched in both its acute and community hospitals, including Exeter Community Hospital; Seaton Community Hospital; Sidmouth Community Hospital; Exmouth Community Hospital; Ottery St Mary Community Hospital; Honiton Community Hospital; and Tiverton Community Hospital.
  33. 33. Antipsychotics in the community Health Services Journal (Oboh, 2014) Every year 180,000 antipsychotic prescriptions are written for dementia patients in England, causing an estimated 1,800 additional deaths and 1,620 cerebrovascular adverse events, according to the Banerjee report in 2009. GPs prescribe most of the antipsychotics in primary care via repeat prescribing, although they are often initiated by prescribers outside primary care. GPs are reluctant to discontinue prescribing in spite of the associated risks and evidence that many patients will have no worsening of symptoms when discontinued.
  34. 34. • Undertake an audit and reduction exercise; and • Identify local experts to provide clinical support to GPs and champions to facilitate collaborative working between primary, acute and mental health teams.
  35. 35. Rights-based advocacy: the importance of the European Convention on Human Rights
  36. 36. • Article 2 – the right to life (with virtually no exceptions) • Article 3 – prohibits inhuman or degrading treatment or punishment (with no exceptions or limitations) • Article 5 – everyone has the right to liberty and security of person (subject to lawful arrest or detention, which can include people with mental disorders)
  37. 37. • Article 6 – everyone has a right to a fair trial (including a to defend himself or herself in person or through legal assistance of his own choosing) • Article 8 – the right to private and family life (subject to certain restrictions that are “in accordance with the law” and “necessary in a democratic society”) • Article 14 – freedom from discrimination, including on the grounds of disability (but only in respect to the person’s rights under the Convention).
  38. 38. Rahman (2015) – work by Swaffer (2014)
  39. 39. World Health Organization “Community based rehabilitation” The aim of community-based rehabilitation (CBR) is to help people with disabilities, by establishing community-based programs for social integration, equalization of opportunities, and rehabilitation programs for the disabled.
  40. 40. Different types of persons using Buurtzog • Chronically ill and functionally disabled clients • Elderlyclientswithmultiplepathology • Clients in a terminal phase • Clientswithsymptomsofdementia • Clients who are released from the hospital and are not yet fully recovered
  41. 41. • Landscape of some services • English dementia strategy • Difference between community and centralised large hospitals • Learning from the acute hospital experience • Dementia friendly environments including ward settings • Specialist nurses and palliative care • Carers • Antipsychotics • Rights, enablement and rehabilitation