This project aims to improve the quality of service for people living with dementia in Oxfordshire by integrating the established care home support service with 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 receive
• Reduceadmission rates and Delayed Transfer of Care

The majority of people in Oxfordshire’s care homes have dementia and many have co- existing physical or mental health needs. Recognition of this full range of complex needs can be difficult for the largely untrained workforce in care homes that often struggle to bring together the physical and the mental aspects of care. We believe this contributes to some inappropriate admissions to homes when people could continue to live in their own community, high admission rates to hospital services and we have the highest 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 and involve several referral points and respond only for specific elements of need. They also have different training which is not linked. Consequently there are gaps and inconsistency in quality of the services.

Learning from elsewhere

The service model of mental health in-reach has been successful in the North East of England, to be delivered locally from a single in-reach team, by integrating practitioners in the existing 3 services and training them to support both care homes and the hospital services so that people with dementia with complex needs receive the most appropriate and personalised service.

Deliverables

• •Development of new roles to provide enhanced mental health expertise within the existing Care Home Support Service team and undertake organisational change to transfer mental health staff’s exiting job roles to new service.
• Training in the“ Newcastle Model” of dementia9 in the care home support service
• Production of protocols for new team operation and assessment and intervention techniques which are delivered directly with people with dementia in care homes, and at points of transfer either  from own home to care home or at transfer between services ,implemented within 6 months of project start.
• Adoption of the “Newcastle Model” of dementia care service working with all care homes in the County with a single( integrated) team thus providing holistic care and a single point of access
• Promotion of new service to GPs in months 6-12.
• Set up liaison protocols with General and Community Hospitals in months 6-12.
• Enhanced Clinical supervision in new way of working in early phase (first 12 months) of project to establish routine practice – by end of 12months the team will have clear operational process and be using the service model as routine, a supervision structure with access to appropriate expertise to work with people with “mild” and “complex” mental health needs will be in place.

Anticipated outcomes

• Improved  quality  of  service  measured  through  routine  service  evaluation questionnaires with care homes, families, primary and secondary care providers who have contact with the service.
• Improved recognition of dementia and people presenting for early diagnosis 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 being rolled out as part of the “training bid”. 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 in 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.