As part of their wider aging and frailty programme of work, Luton CCG has recently implemented a multi-disciplinary, personalised approach to help people with dementia to better manage their ongoing long term conditions.
The main drive for this programme was to identify people over the age of 65 who are at risk of frailty with long term conditions and to proactively work with them to help manage their care. Key to this was to help them remain in their own home with support as opposed to going to a nursing or residential home and help reduce avoidable admissions to hospital.
Since August 2016 all people with dementia and other complex needs over 65 year who are identified by the frailty index in Luton CCG, were offered the primary care home model with their consent.
This model includes up to ninety days of multi-disciplinary, personalised approach for each to person to determine what is most important for them and jointly decide the best way forward. This included a conversation about what is important to them and their family by a community matron which then lead to a jointly developed health and care plan going forward.
Each person receives a thorough health and social care assessment, a review of their current needs and an opportunity to say what was important to them about their health and care needs. This usually leads to blood tests or a memory assessment to investigate any new symptoms, as well as full medicines review. All repeat prescriptions no longer required are ceased with significant financial savings.
In addition, the person is also able to improve their knowledge, skills and confidence but being offered health coaching. This helps them to understand how best to manage their long term conditions fit in with their lifestyle, as well as offering them appropriate advice and equipment to make them more comfortable and remain as independent as possible. This includes advice on welfare benefits, fire hazards, fitting smoke and carbon monoxide alarms and safety checks of their home including telehealth alarms. A handyman is also on hand to fix repairs and keep a spare key safe.
Social care needs were also considered once all of the health needs have been addressed. And if eligible, a carer’s assessment is also offered. Advice about local activities and support in the community and any formal support required was also identified and given. All people with dementia are asked (with their family’s support) to complete a “This is me” profile. Some accept a personal health budget.
Crucially, a person’s personalised care and support plan is shared across the systems and emergency services, as well as their GP and local hospital. This has stopped people having several new tests as the baselines are already recorded and they do not have to keep repeating their story.
All in all, twenty-eight Luton GP surgeries participate and host a virtual multi-disciplinary team within each of their practices. The next stage of the expansion will be to provide this enhanced health care approach within care homes, targeting those with frequent avoidable admission to hospital.