Dementia Services Strategy - Metro South Healthdementia was included as the ninth National Health...

Metro South Health | Dementia Services Strategy 1

Dementia Services Strategy

Dementia Services Strategy

Published by the State of Queensland (Metro South Hospital and Health Service), February 2016

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Metro South Hospital and Health Service) 2016

You are free to copy, communicate and adapt the work, as long as you attribute Metro South Hospital and Health Service.

For more information: metrosouth.health.qld.gov.au


ContentsList of abbreviations 5

Introduction 6

What is dementia? 7

Dementia health service issues 8

Dementia Services Framework 10

Key enablers 11

Service options 12

Services across the management stages of dementia 13

1. Awareness, Recognition and Referral 13

2. Initial Assessment and Diagnosis, and Post Diagnosis Support 14

3. Management, Care, Support and Review 16

4. End of Life 20

Summary of strategies 22

Implementation 23

References 24

Contents

Metro South Health | Dementia Services Strategy4


List of abbreviations

Abbreviation Full term

ACP Advance Care Plan (Planning)

BPSD Behavioural and Psychological Symptoms of Dementia

BSPHN Brisbane South Primary Health Network

DEMOS Dementia Outreach Service

ED Emergency Department

GP General Practitioner

HDU High Dependency Unit

MSH Metro South Health

MSHPCS Metro South Health Palliative Care Service

NGO Non-Government Organisation

PAH Princess Alexandra Hospital

RACF Residential Aged Care Facility

RRC Redland Residential Care


In 2013, dementia and Alzheimer’s disease became the second leading cause of death in Australia, outranking cerebrovascular diseases for the first timei. By 2016, it is predicted that dementia will become the major cause of disability in Queenslandii. In recognition of this, and the increasing impact of quality of life and health resources, dementia was included as the ninth National Health Priority area in 2012.

The Metro South Health Dementia Services Strategy (the Strategy) builds upon the work undertaken by the Commonwealth Department of Social Servicesiii and Queensland Healthii in dementia services planning over recent years. We have reviewed and analysed leading research, evidence-based guidelines and service models for the provision of best-practice dementia care. We have listened to clinicians, service providers and patient, carer and family feedback—on what services are needed and how they should be provided—to improve the quality of life for people living with dementia and their carers and families (refer Metro South Health Dementia Services Strategy—Diagnostics Report iv).

Metro South Health (MSH) embraces the following guiding principlesii in the planning and delivery of our dementia services:

1. People with dementia are valued and respected. Their right to dignity and quality of life is supported

2. Carers and families are valued and supported and their efforts are recognised and encouraged

3. People with dementia, their carers and families are central to making choices about care

4. Service responses recognise people’s individual journeys

5. All people with dementia, their carers and families receive appropriate services that respond to their social, cultural or economic background, geographical location and needs

6. A well-trained supported workforce that delivers quality care

7. Communities play an important role in the quality of life for people with dementia, their carers and families.

People with dementia, and their carers and families, need access to high quality and integrated health care services—from the first stages of awareness and recognition of symptoms, through to end-of-life care. These services should be available in a variety of settings to suit the person and their care needs—such as, in their home or other community setting, primary health care, emergency departments, hospital inpatient beds and outpatient clinics, and aged care facilities. People should be able to access high quality dementia care, regardless of where they live within the Metro South Hospital and Health Service.

This Strategy takes a patient-centred service pathway approach to describing the overarching dementia services framework that should be provided across the management stages of dementia (refer Figure 1) and settings of care, to ensure the delivery of high quality and integrated health care services to people living with dementia and their carers and families.

Introduction

Figure 1: Management stages of dementia

Source: Dementia services pathways—an essential guide to effective service planning (KPMG, 2011)v

1. Awareness, Recognition and

Referral

2. Initial Assessment and Diagnosis, and

Post-Diagnosis Support

3. Management, Care, Support and Review 4. End of Life


This Strategy has been endorsed as the dementia services direction for MSH, with recognition that such endorsement does not represent a commitment by MSH to fund any additional capital and/or operating costs that may be required for implementation. The implementation of the Strategy will include the development of detailed models of care, related workforce and infrastructure plans and business cases required to support funding applications (refer section “Implementation” for further detail).

What is dementia?

Alzheimer’s Australia—the key advocacy group for Australians living with dementia—describes dementia as “a collection of symptoms that are caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life. The hallmark of dementia is the inability to carry out everyday activities as a consequence of diminished cognitive ability.” vi

There are many different forms of dementia and each has its own causes. The most common types of dementia are Alzheimer’s disease (50 to 75 per cent of cases), vascular dementia (20 to 30 per cent of cases), frontotemporal dementia (5 to 10 per cent of cases) and dementia with Lewy bodies (up to 5 per cent of cases). Dementia is usually of gradual onset, progressive in nature and irreversible. There is presently no cure for most forms of dementia; however, some medications have been shown to reduce some symptoms.

While most people with dementia are older, dementia is not a normal part of ageing. The prevalence of dementia increases exponentially with age from about age 65, with advancing age being the key risk factor for developing dementia. While research continues into the specific causes of dementia, other risk factors are thought to include family history of dementia, certain specific gene mutations, stroke, and certain health and lifestyle factors which are known to increase the risk of vascular disease (such as smoking, sedentary lifestyle, obesity etc).vii

Is it dementia? It is important to recognise that a number of conditions can produce symptoms similar to dementia, and can often be treated. These conditions include some vitamin and hormone deficiencies, depression, medication effects, infections and brain tumours. Early medical assessment of symptoms will assist in the correct diagnosis and appropriate treatment pathway.vi


The current dementia health service issues for MSH were identified and prioritised through the review and analysis of relevant literature (e.g. reports, reviews, guidelines), data indicators and stakeholder consultations. These issues are discussed in detail in the Metro South Health Dementia Services Strategy—Diagnostics Report iv. A brief summary of the issues is provided below.

Dementia health service issues

Increasing dementia prevalence and burden of disease

Aboriginal and Torres Strait Islander people

• dementia burden than non-Indigenous population

• Expand the use of culturally sensitive assessment tools

Cultural and Linguistically Diverse

people

• Culturally appropriate services and information in languages other than English

By 2031:

MSH Dementia 119%Prevalence

MSH Population 41%

In 2013:

Dementia and Alzheimer’s became the

second leading cause of deathin Australia

Special needs groups in dementia service planning

In 2011:

Dementia was thefourth leading cause of burden

of diseasein Australia

Younger Onset Dementia

• < 65 years olds developing dementia

• Care needs are different from older groups

Awareness, assessment and diagnosis

• Under-diagnosis and under-disclosureof dementia

• Lack of awareness and understanding of dementia in the community – “normal ageing”, social stigma, fear

• Access to specialist assessment and diagnosis services across community, acute and residential settings

• Timely diagnosis to enable earlier access to appropriate health care and support services

• Caring for someone with dementia can involve significant stress – affecting the physical and mental health of the carer

• Carer support services must be integral to effective holistic dementia care • Carers as full partners in care effective implementation of care plans; reduced care transitions –

providing stability for the person with dementia and their carer and family• Unmet need for respite care – residential care for people with BPSD can be difficult to obtain

Carer support

Workforce education

Perceived lack of awareness and knowledge about dementia

across health workforce

Sub-optimal patient outcomes

Dementia education of the workforce• Identifying cognitive impairment – dementia v delirium• Screening and assessment tools• Specialist referral pathways and protocols• Communication with people with dementia, carers, families• Risk reduction strategies for dementia patients

Lesbian, Gay, Bisexual, Transgender and

Intersex (LGBTI) people

• Particular social and health care needs for LGBTI people living with dementia, as well as their carers, families and friends


Placement of people with severe to extreme BPSD

• Appropriate residential care can be very difficult to obtain – important role of RRC in meeting this need

• Current RRC intake procedures have led to delays in providing best-practice care for people with severe and extreme BPSD

Dementia care in the community

Dementia care in hospitals

Inappropriate use of medications and physical restraints

Concern that in many cases, across different settings of care, physical and chemical restraints are often the first line of response to BPSD when, in most cases, other approaches should be tried first

• Training and education for family / carers and staff across various health care settings

• Access to specialist behaviour management and medication advice

Dementia care in residential aged care

Coordinated, integrated, multidisciplinary approach to dementia care

Transition management

• Ill-managed transitions between settings of care leads to patient and carer distress, acute care readmissions and premature entry to residential care

Coordination of care

• Insufficient coordination of health care for people with dementia, across services and sectors

• Case management of health and social services improves patient and carer outcomes

Multidisciplinary teams (MDTs)

• People with dementia usually have multiple health conditions

• MDTs effective in addressing complex care requirements

• Clear clinical governance is essential

• People with dementia who live in their own homes have limited ability to access health services due to their own/ and or their co-resident carer’s disabilities

• Uncertain impact of Commonwealth aged care reforms on dementia-specific home and community programs

Community-based dementia services targeted at both the person with dementia and their carer:

reduce, delay or prevent care transitions

support people’s preference to remain at home

People over 70 years of age admitted 20%to hospital who have dementia

Patients with dementia or delirium who 50%*do not have a cognitive impairment identified in hospital (* estimated)

Patients with dementia have a significantly increased risk of adverse outcomes and preventable complications

• Identification of dementia on admission or presentation to ED

• Involvement of family / carers• Staff understanding of dementia,

communication with dementia patients, and BPSD responses

• Improve hospital environments to enable better care of people with dementia

• Early and effective discharge planning

Specialist dementia support

• Continued specialist dementia support and education to RACFs in referral-specific behaviour assessment, developing care plans, assisting in the implementation of behaviour management strategies

• access to specialist geriatric medicine input


The MSH Dementia Services Framework has been designed in response to the dementia health service issues identified in the previous section, and is outlined in Figure 2. The Framework is intended to provide an integrated, patient-centred framework of care across the management stages of dementia. It recognises that MSH will work with its service partners and the community, to provide a range of coordinated dementia services to better meet the needs of people living with dementia and their families and carers in MSH.

Dementia Services Framework

Figure 2: Metro South Health Dementia Services Framework

Metro South Health Dementia Services

Framework

3. Management, Care, Supportand Review

1. Awareness, Recognition and Referral 2. Initial Assessment and Diagnosis, and Post-Diagnosis Support

Metro South HealthAlzheimer’s Australia

Families

Carers

Patients

Brisbane SouthPrimary Health Network

NGOs

GPs

Private Health

Providers

Residential Aged Care Facilities

Commonwealth Aged Care

• Services that address individual, community and service provider awareness and recognition of symptoms of dementia (change in skills, behaviour and memory loss), and related supportingbehaviour of acknowledging concernsand referral for investigation.

• Activities include awarenessraising, training and education,and behaviour change.

• Services that may assist with and/or undertake initial assessment and diagnosis, and that provide post-

diagnosis support.

• Services that address the role of ongoing management, care support and review across the spectrum of services and across care settings (such as at home, in the community, in acute care and in residential care).

• Services range from post-diagnosis, addressing fluctuations in needs for care and support services, to more intensive case management and care as the disease progresses.

4. End of Life

• Services, medical and allied health professionals and other supports involved in the planning and provision of quality end of life care in a variety of settings (such

as at home, residential care and hospitals).

Note: Adapted from Dementia services pathways—an essential guide to effective service planning (KPMG, 2011)v


Key enablers

The Framework is based on a solid foundation of strategies to develop the key enabling elements of Clinical Leadership, Partnerships and Choices.

Clinical leadership

As an identified global health issue, there is a growing and rapidly evolving body of research into the causes, prevention and treatment of dementia, as well as models of care for people living with dementia. We are committed to ensuring MSH services for people living with dementia reflect the latest evidence-based clinical research, including for identified special needs groups. Across the management stages of dementia and settings of care, our services will reflect the growing evidence-base for multidisciplinary team approaches to care. We will implement contemporary training and education strategies to ensure the capability of our workforce in translating evidence-based research into delivering quality care for people living with dementia and their families and carers.

Strategy 1: Review aged care clinical leadership frameworks to ensure an ongoing informed, co-ordinated, multidisciplinary approach to the design and capability of MSH dementia services and workforce.

New / Existing Service?

Scope of Change

Additional Resources Required?

Existing aged care clinical leadership

Review frameworks for clinical leadership of dementia care

No

Partnerships

Care and support for people living with dementia and their families and carers are provided by a range of service providers and organisations within the catchment of MSH. We recognise the value of working in partnership to ensure the coordinated and integrated provision of services and avoid service duplication. In particular, we will seek to develop strategic partnerships with Alzheimer’s Australia (Queensland) and the Brisbane South Primary Health Network (BSPHN) in the design and delivery of dementia services and the development of workforce capability.

Within our own services, we value working in partnership with people living with dementia and their families and carers. We will continue to recognise and support families and carers in caring for people with dementia and enabling informed choices about care.

Strategy 2: Develop strategic partnerships with Alzheimer’s Australia (Queensland) and the Brisbane South Primary Health Network (BSPHN) in service design and delivery and the development of workforce capability for dementia services in the MSH service catchment.


Scope of Change


New (Alzheimer’s Australia (Qld)) / Existing (BSPHN)

Increased engagement

Yes


Choices

We recognise that each person’s journey with dementia is unique and we are keen to play our role in a service framework that provides a range of services that respond to individual needs. However, a range of service options and providers can increase confusion for service providers and consumers alike. In response, we will develop and publish an online dementia service pathway to assist service providers, people living with dementia and their families and carers to navigate the dementia services framework and make informed choices about care.

An initiative of MSH, and developed in collaboration with the BSPHN, primary care, private and non-government sectors, SimplyHealth Professional is an online care pathway tool which enables coordination and integration of care for patients where they need it, when they need it.

The development of the dementia care pathway in SimplyHealth will involve consultation with other key service providers such as Alzheimer’s Australia (including the Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Teams (SBRTs)—both Australian Government initiatives), NGOs and relevant private health options.

Strategy 3: Develop and promote the use of an online dementia care pathway through SimplyHealth, which includes the range of service options provided by MSH, as well as other public, NGO and private service providers.New / Existing Service?

Scope of Change


Existing tool. New care pathway.

New dementia care pathway.

No. Within current SimplyHealth Team

Service options

The design of our Dementia Services Framework has been guided by an analysis of contemporary dementia service options from a variety of sources, including:

• Commonwealth and State service frameworks, plans and strategies ii, iii, viii, ix, x

• Evidence-based clinical guidelines and models of care xx, xi, xii, xiii, xiv, xv, xvi, xvii, v

• Consumer feedback. xviii, xix


1. Awareness, Recognition and Referral

1. Awareness, Recognition and Referral

This stage addresses individual, community and service provider awareness and recognition of symptoms of dementia (change in skills, behaviour and memory loss), and related supporting behaviour of acknowledging concerns and referral for investigation. The stage includes awareness raising, training and education, and behaviour change.

Alzheimer’s Australia (Qld) is the peak body for providing awareness and recognition programs for people living with dementia, their families and carers, as well as for health and aged care professionals.

People living with (or suspected) dementia are likely to present to a range of MSH services across various settings of care. In many cases, cognition issues may not be the main reason for presentation, but are almost certain to impact their care pathway. We will facilitate dementia awareness and recognition programs for our staff across all settings of care to increase workforce capability in this area. Within our hospitals, dementia workforce education will be coordinated through the proposed Dementia/Delirium High Dependency Units (HDUs) (see Stage 3). We will ensure that available resources from organisations such as Alzheimer’s Australia (Qld), leading research groups, and Commonwealth-funded programs are appropriately utilised in the development and delivery of these programs.

As previously stated, we will develop an online dementia care pathway in SimplyHealth to assist service providers in identifying appropriate referral pathways for patients/clients.

Strategy 4: Facilitate the development and delivery of dementia education programs for MSH staff, including awareness, recognition and practice change strategies (including for special needs groups), to deliver best-practice care to patients with (or suspected) dementia and/or delirium.New / Existing Service?

Scope of Change


Existing (at PAH)

Expand to other facilities

Yes

Services across the management stages of dementia


2. Initial Assessment and Diagnosis, and Post-Diagnosis Support

2. Initial Assessment and Diagnosis, and Post-Diagnosis Support

This stage addresses the spectrum of services that may assist with and/or undertake initial assessment and diagnosis, and that provide post-diagnosis support.

Home, Community and Residential Care

Following the recognition of symptoms of cognitive decline in the home, community or residential care facility, most people should self-refer or be referred by family/friends or carer to their primary care provider (GP) for initial assessment and diagnosis. There are also private geriatricians in the region who will accept direct referrals from patients or via a GP. The development of a post-diagnosis care plan will identify the health and social interventions required for post diagnosis support of the person with dementia and their carer. A multidisciplinary approach to assessment, diagnosis and care plan development is recommended. MSH’s planned development of an online dementia care pathway in SimplyHealth will assist in identifying the most appropriate post-diagnosis support services.

People with suspected dementia may experience limited access to primary health care for a variety of reasons, including the decline in their cognitive status and/or resistance due to lack of insight, the existence of co-morbidities restricting mobility, or a lack of effective social/family support. Outreach services are essential to assist these vulnerable members of our community. MSH will engage with external service providers to review and improve access to outreach services for dementia assessment, diagnosis and post-diagnosis support services across the MSH service catchment.

Strategy 5: Engage with external service providers to review and improve access to outreach services for dementia assessment, diagnosis and post-diagnosis support services across the MSH service catchment. New / Existing Service?

Scope of Change


New

Engagement and service review

Yes

MSH Outpatient Services

The MSH Memory Clinic is an HHS-wide service, located at the PAH, which specialises in the secondary assessment and diagnosis of cognitive impairment. It will continue to provide clinical leadership for complex assessment and diagnosis of cognitive impairment in MSH. Geriatric medicine outpatient clinics currently operate at the PAH, QEII Jubilee, Logan and Redland Hospitals. These clinics see patients for a wide variety of geriatric-related illnesses or syndromes, including dementia.

GPs should remain the primary referral pathway for assessment and diagnosis of dementia. However, in situations where a clear dementia diagnosis and/or cognitive functional assessment has not been able to be achieved in a primary care setting, the MSH Memory Clinic and geriatric outpatient clinics can facilitate secondary assessment and diagnosis services, following referral from a GP or other medical specialist. For example, assessment and diagnosis by a geriatrician may be required in complex clinical cases, where multiple co-morbidities are present in a patient.

It is envisaged that current referral pathways described above will not change and should continue to be coordinated via the MSH Central Referral Hub. It is recommended that the referral criteria for the MSH Memory Clinic and geriatric medicine outpatient services be revised where necessary to maintain the focus on secondary dementia assessment and diagnosis services for complex patients.

The geriatric medicine outpatient clinics at the QEII Jubilee, Logan and Redland Hospitals would all benefit from increased access to multidisciplinary input to assist in cognitive and functional assessment and the development of post-diagnosis care plans for patients.


Strategy 6: Review dementia referral criteria for the MSH Memory Clinic and geriatric medicine outpatient clinics as necessary to maintain the focus on secondary dementia assessment and diagnosis services for complex patients.New / Existing Service?

Scope of Change


Existing

Review of referral criteria

No

Strategy 7: Provide geriatric medicine outpatient clinics with increased access to multidisciplinary input to assist in cognitive and functional assessment and the development of post-diagnosis care plans for patients.


Scope of Change


Existing

Expand multidisciplinary input

Yes MSH Acute Inpatient Care

For inpatients with suspected dementia, a cognitive and functional assessment and diagnosis may be needed for effective treatment in their acute episode of care (in ED or an inpatient unit). Consultations are sought from specialist services as required, including geriatricians, mental health, allied health, palliative care (advance care planning) and others. A multidisciplinary approach to assessment, diagnosis and care plan development is recommended. We will ensure that clear consultation protocols exist in all facilities for patients with suspected dementia requiring multidisciplinary cognitive and functional assessment and diagnosis.

For acute inpatients demonstrating BPSD, inpatient assessment and diagnosis for dementia may be more appropriately conducted in the planned Dementia/Delirium HDUs (see Stage 3).

For patients demonstrating BPSD in the absence of any acute illness or surgical requirement which would require hospitalisation in an acute facility for treatment, referral to the planned Cognitive Assessment and Management Unit (CAMU) (see Stage 3) for initial assessment and diagnosis is advised.

Strategy 8: Review models of care across all settings to ensure a multidisciplinary team approach to the assessment, diagnosis, care planning, treatment and support of people with (or suspected) dementia and their families and carers in MSH services.


Scope of Change


New

Review consulting protocols

Yes

Post-Diagnosis Support

MSH will ensure that post-diagnosis care plans—developed in consultation with the patient, their family and/or carer—refer patients to appropriate post-diagnosis support services (as identified through the planned SimplyHealth dementia care pathway). A variety of post-diagnosis service options to suit individual patient needs are available from MSH, as well as other public, NGO and private service providers.

Strategy 9: Review MSH post-diagnosis care planning processes for people with dementia to ensure that a wide range of post-diagnosis support services (from both MSH and/or external providers) are considered.New / Existing Service?

Scope of Change


Existing

Process review

Yes


3. Management, Care, Support and Review

This stage addresses the role of ongoing management, care support and review across the spectrum of services and across care settings (such as at home, in the community, in acute care and in residential care). Services range from post-diagnosis, addressing fluctuations in needs for care and support services, to more intensive case management and care as the disease progresses.

3. Management, Care, Support and Review

Home, Community and Residential Aged Care

A variety of ongoing dementia management, care support and review services are available from a range of service providers, providing choice for consumers, their families and carers.

Alzheimer’s Australia (Qld) offers a range of support services—including information, education, counselling and support groups—for people living with dementia, their families and carers, as well as for health and aged care professionals. A range of support services are available for Aboriginal and Torres Strait Islander people, Cultural and Linguistically Diverse people, LGBTI people and people with younger onset dementia.

People with dementia, their families and carers, are also encouraged to maintain a relationship with their GP or private specialist for ongoing review to address fluctuations in care needs as the disease progresses.

Care transitions—changes to the level and setting of care—can exacerbate BPSD for people with dementia, and may cause increased stress for families and carers. MSH provides a range of home and community-based services to provide acute and post-acute health care needs in the home, which ease transitions and reduce lengths of stay in hospital. In addition, Commonwealth-funded services operated by NGOs also provide home support services which can assist people with dementia to remain living at home. In conjunction with external service providers, MSH will review service strategies to reduce acute care transitions from RACFs for people with dementia.

The challenge of managing BPSD in the home or RACF environment is a key reason for care transitions for people living with dementia. The provision of effective outreach services to provide assistance to home and RACF-based carers in effectively managing BPSD can reduce or delay care transitions, facilitate a higher quality of care for people living with dementia, and reduce family and carer stress.

MSH’s Dementia Outreach Service (DEMOS) provides both short-term home-based dementia care services to MSH residents living with dementia and who have “complex needs”1, as well as an RACF outreach service which assists RACFs to better manage people with BPSD, while at the same time building staff capacity. Alzheimer’s Australia (Qld) operates the Dementia Behaviour Management Advisory Service (DBMAS), as well as referrals to the Severe Behaviour Response Teams (SBRTs), which provide behaviour management education and support for care workers, family carers and service providers.

1 Complex needs may include any, or all, of the following:

• Requires coordination of multiple clinical interventions and responses (short term intensive case management)

• An identified high risk of ED presentation due to dementia and complex comorbidities (including alcohol related), unmanaged BPSD, dual diagnosis, delirium/underlying medical issue, and/or situational crisis

• Recent or pending hospital discharge with potential for readmission due to psychosocial factors including carer capability to manage patient’s ongoing care

• Limited access to medical/healthcare including difficulty obtaining a diagnosis

• BPSD which are not able to be managed with psychosocial and pharmacological interventions

• Lives alone with no or minimal support and is at risk in the community.


MSH will engage with Alzheimer’s Australia (Qld) to ensure the effective and coordinated provision of multidisciplinary outreach BPSD support services within the MSH catchment.

There are a variety of RACFs across MSH providing residential aged care for people with dementia. In MSH, the Acacia Unit at Redland Residential Care (RRC) is a 32-bed secure dementia unit, providing residential aged care for complex, mobile residents with dementia who have been unable to obtain and/or maintain placements in NGO RACFs due to severe BPSD.

Research indicates that the optimal size for specialised dementia units in RACFs is in the range of 8–14 residents xx, xxi, xxii. It is recommended that the current Acacia Unit at RRC be reconfigured to accommodate a smaller 8-12 bed residential dementia unit, in recognition of both optimal unit size guidelines, as well as to enable flexible spaces within the building design to support the management of smaller groups or one person, as required. The reconfiguration will incorporate best practice environmental design principles for people with dementia, allowing appropriate space to reduce agitation and distress, support independence and social interaction, promote safety and enable activities of daily living xxiii.

The admission criteria for RRC will continue to target MSH residents with dementia who have been unable to obtain and/or maintain placements in NGO RACFs due to severe BPSD. In line with best-practice models residential aged care for people with dementia, the RRC model of care will take a multidisciplinary team approach.

The remaining footprint of the current 32-bed unit will be assessed for its suitability in accommodating the proposed sub-acute CAMU (detailed in the “Sub-acute Inpatient” section below).

The Boronia Unit at RRC will provide step-down behaviour residential aged care for residents with reduced mobility, but still presenting with significant BPSD affecting their ability to be placed in a NGO RACF. Patients with reduced mobility could otherwise be at risk if co-located with more mobile residents with severe BPSD in the Acacia Unit. The Boronia Unit also provides residential aged care to residents with behaviours related to mental illness, who do not quite meet the rehabilitative model for the psychogeriatric (Daintree) unit. As mobility reduces even further, RRC residents with dementia can be transitioned to a general frail aged bed within the facility for appropriate end-of-life care.

The current admission process for the RRC Dementia Unit excludes the ability for direct admission from the community. This has resulted in inappropriate transfers to EDs from RACFs and admissions to MSH facilities of people with dementia exhibiting difficult BPSD in the absence of other conditions warranting hospital treatment. It is recommended that RRC admission procedures be reviewed to enable the direct admission from the community to the RRC Dementia Unit for people meeting the complex needs criteria.

This Strategy does not propose any change to the current psychogeriatric (Daintree) unit at RRC.

Strategy 10: Engage with external service providers to review service strategies aimed at reducing acute care transitions from RACFs for people with dementia.


Scope of Change


Existing

Service review

Yes

Strategy 11: Engage with Alzheimer’s Australia (Qld) to ensure the effective and coordinated provision of multidisciplinary outreach BPSD support services within the MSH catchment.


Scope of Change


Existing

Service review

Yes


Strategy 12: Reconfigure the Dementia Unit at Redland Residential Care (RRC) to accommodate a smaller 8-12 bed residential dementia unit, incorporating good built environmental design principles, to better meet the behaviour management needs of residents with dementia.New / Existing Service?

Scope of Change


Existing

Service and infrastructure redesign

Yes. Moderate building works required.

Strategy 13: Review RRC admission procedures to enable the direct admission from the community to the RRC Dementia Unit for people meeting the complex needs criteria. New / Existing Service?

Scope of Change


Existing

Process review

No

MSH Acute Inpatient Care

An 8-bed Dementia/Delirium High Dependency Unit (HDU) currently operates at the PAH. It is recommended that this service model be expanded to other MSH facilities, with the establishment of Dementia/Delirium HDUs at QEII Jubilee Hospital, Logan Hospital and Redland Hospital. The size of each HDU will be determined through staff consultation and analysis of relevant admissions data at each facility.

The HDUs will provide an appropriate and safe environment (although not locked) in which to provide high quality care for patients admitted for medical or surgical treatment, who also have behaviours associated with (or suspected) dementia and/or delirium. Such behaviours—often exacerbated by admission to an unfamiliar hospital setting—may make it difficult to provide appropriate medical care in a usual ward setting. The HDUs will incorporate good built environmental design principles for dementia spaces to reduce agitation and distress, support independence and social interaction, promote safety and enable activities of daily living xxiii.

This Strategy recommends that people requiring assessment and management of BPSD in a facility setting in the absence of an acute medical condition should not be admitted to an acute medical ward or HDU. The proposed sub-acute Cognitive Assessment and Management Unit (CAMU) (see below) is recommended as the most appropriate care setting in these cases.

The HDUs will have access to a multidisciplinary staff profile, with consultations from other specialties as required. Clear procedures for admission to the new HDUs will be developed in consultation with key geriatric medicine, general medicine, surgical and nursing staff at each facility. At any point in time, it is envisaged that patients with the most severe behaviours will be prioritised for care in these HDUs. Clinical governance for the patients in the HDUs will remain with the admitting physician.

The HDUs will facilitate:

• workforce education and practice change2 strategies to improve staff abilities to:

- recognise and assess cognitive impairment symptoms

- embed behavioural management care strategies.

2 With an emphasis on up-skilling ward staff, a practice change model embodies such concepts as “teachable moments at the bedside” in order to facilitate and embed new knowledge and approaches to care.


• active involvement of the patient’s family and/or carer (e.g. RACF) in the care of the patient, including:

- in the development of individualised care plans for patients with cognitive impairment

- carer education as required on behaviour management strategies.

• discharge planning including referral and hand-over to appropriate home and/or community-based services.

Strategy 14: Establish Dementia/Delirium High Dependency Units (HDUs) at QEII Jubilee Hospital, Logan Hospital and Redland Hospital, based on the existing PAH service model.

- To provide high quality multidisciplinary care for patients admitted for medical or surgical treatment, who also have (or suspected) dementia and/or delirium.

. New / Existing Service?

Scope of Change


Existing

Expand service to other facilities

Yes. Additional staffing, minor building works required.

MSH Sub-acute Inpatient Care

It is recommended that a 10-12 bed Cognitive Assessment and Management Unit (CAMU) be established and co-located with existing dementia specialist services at the Redland Residential Care site. The CAMU will be a sub-acute inpatient service providing cognitive assessment and management in a secure setting for patients with complex cognitive impairment and/or BPSD, in the absence of any acute illness or surgical requirement which would require hospitalisation in an acute facility for treatment. As such, the CAMU provides a more appropriate treatment pathway for these patients who would otherwise be admitted to acute medical wards.

The goal of the CAMU will be to provide a time-limited service to optimise the level at which the patient can function using behaviour management strategies, medication(s) and a secure environment. From this it is hoped to be able to facilitate returning the person with dementia to their family and home environment in a supported way, or provide assistance with planning for placement in an appropriate RACF.

The CAMU will operate under the clinical governance of a senior geriatrician, supported by a multidisciplinary team, with consultations from various other specialties as required. It will be able to accept transfers from Metro South Health EDs and acute inpatient facilities, as well as direct admissions from the community and RACFs that meet the referral criteria. Referral criteria and pathways for the CAMU will be fully developed during the model of care development, but will focus on people residing with the MSH catchment area with:

• a diagnosis of (or suspected) dementia (significant cognitive impairment)

• the absence of an acute illness requiring hospitalisation in an acute facility

• a requirement for care in a secure environment

• an indicative plan for treatment, care and discharge goals.

Strategy 15: Establish a 10-12 bed Cognitive Assessment and Management Unit (CAMU) co-located with existing dementia specialist services at Redland Residential Care.

- To provide sub-acute cognitive assessment and management in a secure setting for patients with complex cognitive impairment and/or BPSD,

- For patients living with (or suspected) dementia in the absence of any acute illness or surgical requirement which would require hospitalisation in an acute facility for treatment.


Scope of Change


New

New 10-12 bed secure unit. Model of care design.

Yes. Additional staffing, moderate building works required.


4. End of Life

4. End of Life

This stage addresses the spectrum of services, medical and allied health professionals and other supports involved in the planning and provision of quality end of life care in a variety of settings (such as at home, residential care, hospice and hospitals).

End-of-life care helps people with advanced, progressive, incurable illness to live as well as possible until they die. The primary intent of end-of-life care is a shift from life prolongation to a focus on quality of remaining life. Effective planning for end-of-life care (known as advance care planning (ACP)) should involve the person with dementia, their families and carers. The ACP process should be initiated as soon as practicable following a dementia diagnosis, to give the person with dementia the greatest opportunity to express their preferences for future treatment and care.

My Care My Choicesxxiv is the MSH-wide strategy for ACP. Launched in 2015, MSH will ensure that My Care My Choices is implemented across our health service to embed end-of-life planning in all of our clinicians’ standard practice.

There are a variety of service providers (public, private and NGO) delivering—and/or providing support to informal carers to deliver—end-of-life care to people with dementia in the MSH catchment. In MSH, the Metro South Health Palliative Care Service (MSHPCS) provides a specialist palliative care service with consultancy, shared and direct care elements that work in collaboration with primary and tertiary care providers to provide end-of-life care. MSHPCS provides end-of-life care across home, residential care, community and hospital settings of care.

Strategy 16: Implement the MSH End-of-Life Strategy (My Care My Choices) across the health service to embed end-of-life planning in all of our clinicians’ standard practice.


Scope of Change


Existing strategy

Embed processes

Yes


Summary of strategies

1. Review aged care clinical leadership frameworks to ensure an ongoing informed, co-ordinated, multidisciplinary approach to the design and capability of MSH dementia services and workforce.

2. Develop strategic partnerships with Alzheimer’s Australia (Queensland) and the Brisbane South Primary Health Network (BSPHN) in service design and delivery and the development of workforce capability for dementia services in the MSH service catchment.

3. Develop and promote the use of an online dementia care pathway through SimplyHealth, which includes the range of service options provided by MSH, as well as other public, NGO and private service providers.

4. Facilitate the development and delivery of dementia education programs for MSH staff, including awareness, recognition and practice change strategies (including for special needs groups), to deliver best-practice care to patients with (or suspected) dementia and/or delirium.

5. Engage with external service providers to review and improve access to outreach services for dementia assessment, diagnosis and post-diagnosis support services across the MSH service catchment.

6. Review dementia referral criteria for the MSH Memory Clinic and geriatric medicine outpatient clinics as necessary to maintain the focus on secondary dementiaassessment and diagnosis services for complex patients.

7. Provide geriatric medicine outpatient clinics with increased access to multidisciplinary input to assist in cognitive and functional assessment and the development of post-diagnosis care plans for patients.

8. Review models of care across all settings to ensure a multidisciplinary team approach to the assessment, diagnosis, care planning, treatment and support of people with (or suspected) dementia and their families and carers in MSH services.

9. Review MSH post-diagnosis care planning processes for people with dementia to ensure that a wide range of post-diagnosis support services (from both MSH and/or external providers) are considered.

10. Engage with external service providers to review service strategies aimed at reducing acute care transitions from RACFs for people with dementia.

11. Engage with Alzheimer’s Australia (Qld) to ensure the effective and coordinated provision of multidisciplinary outreach BPSD support services within the MSH catchment.

12. Reconfigure the Dementia Unit at Redland Residential Care (RRC) to accommodate a smaller 8-12 bed residential dementia unit, incorporating good built environmental design principles, to better meet the behaviour management needs of residents with dementia.

StrategyAdditional Resources Required?

No

Yes

No

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes


Following endorsement of the MSH Dementia Services Strategy by the MSH Executive Planning Committee, the Strategy will be handed over to the MSH Aged Care and Rehabilitation clinical services stream for implementation. Planning, Engagement and Reform will work with the clinical services stream to enable implementation activities as required.

It is important to note that endorsement of this Strategy by the MSH Executive Planning Committee does not represent a commitment by MSH to fund any additional capital and/or operating costs that may be required for implementation.

Key activities in the implementation of the Strategy will include:

• Models of Care development for each dementia service, including detailed assessment of workforce and infrastructure requirements

• infrastructure specifications development for any building works required, including alignment to MSH Master Plan and 3-Year Facility Plans

• business case/s development for additional required funding (both capital and operational), and submission to the Executive Planning Committee for approval

• performance monitoring including the establishment of key performance indicators and baseline reporting

• support implementation

• transition to “business as usual”.


Strategy

13. Review RRC admission procedures to enable the direct admission from the community to the RRC Dementia Unit for people meeting the complex needs criteria.

14. Establish Dementia/Delirium High Dependency Units (HDUs) at QEII Jubilee Hospital, Logan Hospital and Redland Hospital, based on the existing PAH service model.

- To provide high quality multidisciplinary care for patients admitted for medical or surgical treatment, who also have (or suspected) dementia and/or delirium.

15. Establish a 10-12 bed Cognitive Assessment and Management Unit (CAMU) co-located with existing dementia specialist services at Redland Residential Care.

- To provide sub-acute cognitive assessment and management in a secure setting for patients with complex cognitive impairment and/or BPSD,

- For patients living with (or suspected) dementia in the absence of any acute illness or surgical requirement which would require hospitalisation in an acute facility for treatment.

16. Implement the MSH End-of-Life Strategy (My Care My Choices) across the health service to embed end-of-life planning in all of our clinicians’ standard practice.

Yes

Yes

Yes

No

Implementation


i Australian Bureau of Statistics. 3303.0 – Causes of Death, Australia, 2013. ABS, Canberra: 2015

ii State of Queensland (Queensland Health). Queensland Health Dementia Framework 2010-2014. State of Queensland (Queensland Health), Brisbane: 2010

iii Australian Department of Social Services. National Framework for Action on Dementia 2015-2019. DSS, Canberra: 2015

iv Metro South Health. Dementia Services Strategy—Diagnostics Report. MSH, Brisbane: 2015

v KPMG. Dementia services pathways—an essential guide to effective service planning. DoHA, Canberra: 2011

vi Alzheimer’s Australia. Help Sheet 01: What is dementia? https://fightdementia.org.au/sites/default/files/helpsheets/Helpsheet-AboutDementia01-WhatIsDementia_english.pdf (Downloaded 18 August 2015)

vii Australian Institute of Health and Welfare. Dementia in Australia. Cat. No. AGE 70. AIHW, Canberra: 2012

viii State of New South Wales (Department of Health). The NSW Dementia Services Framework 2010-2015. Sydney: 2011

ix State of New South Wales (Sydney Local Health District). Sydney Inner West Dementia Action Plan 2013-2018. Sydney: 2013

x State of South Australia (Department for Families and Communities). South Australia’s Dementia Action Plan 2009-2012. Adelaide: 2009

xi Brodaty H, Draper BM, Low L. Behavioural and psychological symptoms of dementia: A seven-tiered model of service delivery. Med J Aust 2003; 178: 321-324

xii Cognitive Decline Partnership Centre. Clinical Practice Guidelines for Dementia in Australia. Public Consultation Draft. Sydney: 2015

xiii Australian Government (Department of Social Services). Phase One—Severe Behaviour Response Teams: Operational Guidelines. Canberra: 2015

xiv Griffith University, Queensland Health. Dementia Outreach Service (DEMOS) Evaluation—Final Report for Distribution. Brisbane: 2010

xv Moonee Valley Melbourne Primary Care Partnership. Interagency Dementia Care Planning Protocol. Melbourne: 2007

xvi State of Victoria (Department of Health). Cognitive Dementia and Memory Service Best Practice Guidelines. Melbourne: 2013

xvii State of Western Australia (Department of Health). Dementia Model of Care. Perth: 2011

xviii Alzheimer’s Australia. Communique: National Consumer Summit 2015. Canberra: 2015

xix Alzheimer’s Australia. Younger Onset Dementia: A New Horizon? National Consumer Summit 19-20 March 2013. Canberra: 2013

xx Alzheimer’s Australia. Dementia Care and the Built Environment. Position Paper 3. June 2004. Canberra: 2004

xxi Fleming, R. & Purandare, N. Long-term care for people with dementia: environmental design guidelines. International Psychogeriatrics 2010, 22 (7), 1084-1096.

References


xxii Chmielewski, E. Excellence in Design: Optimal Living Space for People With Alzheimer’s Disease and Related Dementias. Perkins Eastman, New York: 2014.

xxiii Australian Commission on Safety and Quality in Health Care. A better way to care: Safe and high-quality care for patients with cognitive impairment (dementia and delirium) in hospital. ACSQHC, Sydney: 2014.

xxiv Metro South Health. Advance Care Planning. https://metrosouth.health.qld.gov.au/acp (Accessed 14 January 2016).

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