Background
The Four Localities Partnership brings together a range of health and care providers and commissioners across the localities of Bury, Oldham, Rochdale and Salford delivering care for a combined population of approximately 1 million people. Within this, the Northern Care Alliance NHS Foundation Trust is a combined acute/community provider that brings together staff and services to deliver a range of integrated health and social care services across the area.
Addressing challenges around patient flow for patients with dementia
The Northern Care Alliance NHS Foundation Trust is working closely with the four place-based partnerships in its system to explore innovative ways of improving patient flow across the area. This work includes a particular focus on supporting people with dementia – a group that are disproportionately represented in hospital admissions and stays in the patch. This case study explores that aspect of the trust's work in particular.
The trust and its place partners want to implement a range of strategies to improve patient experience by supporting patients to be more physically and mentally active as part of their hospital recovery, with the aim of preventing hospital readmissions through enhanced in hospital support. The trust recognises that staying in hospital longer than needed can lead to poorer outcomes including loss of independence and physical deconditioning for older people. It is therefore vital they take the right steps to allow individuals to return to their usual home as soon as it is safe to do so.
The Northern Care Alliance NHS Foundation Trust's discharge frontrunner pilot includes a dedicated focus on dementia, deconditioning and strength-based approaches to discharge, alongside a wider view of pathways. The trust has split this programme of work into two key workstreams to look at:
- How alternative delivery and funding models can be used to provide innovative care to those with complex dementia.
- The adoption of a strength-based approach to care management and discharge.
The two workstreams were developed following a 'discovery phase' undertaken by the Northern Care Alliance NHS Foundation Trust and partners. As part of this, health leaders looked at data surrounding patient flow, the number of people with a diagnosis of dementia compared to the number of dementia related emergency admissions, the number of people living with the dementia in their area and the related costs to delivering these services.
From this, they determined that approximately one in six people residing in a non-elective bed in the area had dementia. By 2030, this is predicted to be at least one in three, highlighting the need to think differently about how these patients are cared for.
Rochdale Oasis Unit
Reflecting the need to better to support those who suffer with dementia, Rochdale Infirmary (an acute site at the trust) has developed an Oasis unit, which is a 10 bedded medical unit specifically designed to care for patients living with dementia or a cognitive impairment. The unit is open 24/7 and provides inpatient care with a dedicated nursing and medical team working alongside dedicated mental health nurses who support families, carers and link in with care homes directly to support individuals upon discharge.
Patients are referred to the unit if they are unwell and live with dementia. Referrals can be taken from a GP, A&E and other community services in the local area. The team delivers care for patients until they are well enough to go home.
Delivering this kind of multidisciplinary care ensures dementia patients are cared for in a way that suits their unique needs and circumstances. Patients are supported to walk, get dressed, sit up and participate in a full time activity programme to avoid agitation. Families are encouraged to visit to maintain familiarity and consistency, and patients are given additional support throughout the night.
Key enablers
Leaders at Northern Care Alliance NHS Foundation Trust were clear that having a strong history of collaboration with partners across and within the four places has been a key enabler to developing this work. Each place shares some common features, particularly around their objectives and priorities on promoting prevention and improving care for local communities.
The trust has also started to shift the language around how they measure time spent in hospital. For example, it has stopped using terminology such as 'no criteria to reside' and instead talks about 'days kept from familiar places'. This shift in language promotes a more holistic view of care, with the core purpose of discharge being to help someone return to the best and most suitable environment for them. The trust is keen to avoid seeing all conditions through an illness model and instead wants to better understand what alternative support could be provided beyond purely health services.
Key barriers
One barrier to delivering integrated care for dementia patients more consistently across the four places is the differences in historical commissioning decisions. Although there are a lot of similarities between each place, the discharge to assess provision ranges in each locality in terms of what care people receive both in hospital and post-discharge, especially for those who suffer with dementia. This variation in provision can create inequity and cause gaps in care for patients, with consequences elsewhere in the system.
Benefits for staff, patients and system flow
It is clear that delivering more tailored care in a 'dementia friendly environment' for those with complex dementia can reduce the length of time an individual remains in hospital, with length of stay for those receiving care in the Oasis unit going from 12 to four days.
The multi-disciplinary approach to supporting those with dementia also ensures patients and their families are being cared for in a more holistic way. For example, the role of the mental health nurse within the Oasis unit is to support the family, carers and link in with the mental health team on discharge from hospital. This allows individuals to be supported in a more person-centred way, thus preventing the risk of significant deterioration.
This can also help alleviate pressure on social care services post discharge. It is clear that, in some cases, spending time in hospital can inadvertently contribute to deconditioning, which in turn can mean people need more acute social care support post-discharge.
Looking ahead
Given the opportunities and benefits presented by delivering more integrated care for dementia patients, Northern Care Alliance NHS Foundation Trust are now looking to expand the use of Oasis units and test this approach at busier hospital sites.
The trust also recognises the need to promote admission avoidance to prevent people going into hospital in the first place. As part of this, the trust and partners are utilising urgent community response services to support people to stay well at home. They are also looking at what this means for people with dementia specifically, with a view to developing more integrated working with mental health services in the area to better understand how people can be supported to remain at home.