Royal Cornwall Hospitals NHS Trust is leading the national challenge against dementia after implementing new software designed to support the health service trusts with the early diagnosis and improved care of patients with dementia. Frazer Underwood, associate director of nursing and consultant nurse for older people at the trust explains the approach taken to collect important patient information that has the potential to redesign services and help meet quality initiatives, set by the Department of Health.
A national problem
The affects of an aging population are taking its toll on today's society, with dementia being one of the biggest areas of concern for the National Health Service. There is an increasing number of dementia cases in the UK each year, currently at an estimated 800,000 people, a figure expected to double by 2040.
In England alone more than 25% of general hospital patients who have been diagnosed with dementia are occupying beds at any one time, and Underwood recognises a culture change is required to support new technology: "The health service and its partners across the county need to be proactive in addressing dementia, from GPs' diagnosis to support services led by the third sector.
"As a county, we need to make sure that dementia is everybody's business, and not just that of the older care team's. It is a difficult management challenge - to change those types of cultures, and the national agenda around dementia is driving that culture change - changing attitudes of communities and hospital staff."
The trust, a principal provider of acute care services in the county, serves a population of around 450,000 people, a figure often doubled by holidaymakers during the busiest times of the year. "We are ambitious about improving our dementia care; in Cornwall, there are 10% more older people than the national average and the prevalence of dementia correlates with that higher figure."
Identifying dementia - the earlier, the better
Currently only around 42% of people with dementia in England have a formal diagnosis. The opportunity for healthcare providers is not to improve identification rates, but diagnose patients earlier supporting more accurate referrals to the appropriate diagnostic assessment, treatment and support leading to improvements in patient safety and continuity of care.
The national dementia agenda Underwood refers to is the Department of Health's dementia Commissioning for Quality and Innovation (CQUIN) targets, which incentivise the early identification of patients with dementia and other causes of cognitive impairment.
Following a partnership with IMS MAXIMS, the trust became one of the first in the country to exceed all its CQUIN targets for dementia care in March 2013. Integral to this success was the deployment of the collaborative development of dementia-specific software.
Underwood continues: "This software means we are able to ensure that all patients over 75 years old are identified, assessed and referred as appropriate. It enables us to increase the early identification of people with dementia and prompt appropriate referral and follow up after they leave hospital."
With the ability to integrate with virtually any system, the software enabled the trust to:
- capture data to improve the identification, and quality of care of dementia patients
- take users step-by-step through CQUIN targets allowing the easy collation of data ready for extraction
- create a dementia record for each patient who meets CQUIN criteria
- keep inline with the National Institute for Health and Clinical Excellence’s (NICE) guidelines to improve their patient care pathways
The Dementia CQUIN incentivises the [1] identification, [2] assessment and [3] referral of dementia cases and triggered a financial reward by achieving over 90% in all three stages. The trust achieved 99.29%, 100% and 100% in all three stages respectively; the new dementia software helped the trust comprehensively perform to this level in March 2013.
Clinicians from the trust input data at the identification stage, and once this was complete, stages two and three achieved 100% as this is automated by the dementia software. As a result, the trust met the CQUIN targets and retained a financial incentive worth £392,750.
"To be able to have a system and a process in place in our organisation that can deliver CQUIN targets, and deliver it reasonably simply and not too labour intensively is really good for us, especially given the older population and prevalence of dementia in our community."
Getting the diagnosis
Before implementing the software, the trust, which is responsible for the provision of services at three sites comprising approximately 750 beds, did not have a system that captured information specifically on cognitive conditions when elderly patients were admitted to hospital.
The trust opted for the electronic-based dementia software, as capturing information on paper alone through a series of screenings, would be time-consuming, often duplicating staff efforts, and not easily accessible for clinical decision-making. The software allows users to follow a simple worklist so that patients can be identified as having delirium or dementia within 72 hours of admittance.
"Since deploying the software, we have been through a peer review process for our dementia services, and other trusts have been very impressed. These trusts are working with paper systems and have not been able to hit their CQUIN targets, so being able to deliver them has really helped us lead the way in dementia care provision."
The dementia software enables healthcare professionals to:
- reduce administration levels
- streamline the care pathway (for inclusive eligible patients)
- access real-time information quickly and accurately, all in one place
- support handovers and transfers
- reduce unnecessary duplication of data input
By screening patients through a FAIR worklist (Find, Assess & Investigate, Refer), data about their current condition is recorded and easily accessible for both primary and acute care settings. This supports quicker, more accurate decision-making, enabling better clinical performance in acute care, whilst empowering more manageable care of long-term conditions in the community.
"As we continue to develop our electronic patient record capabilities, we are in between paper and electronic systems - which is a huge challenge. Our admission paperwork contains a dementia and delirium screening section which we collect and now transfer into MAXIMS. By inputting the outcomes of the screening assessment into the MAXIMS system we are changing our culture by bridging the gap between paper and electronic data capture - this also helps us start the electronic discharge process. The searchable worklist is really simple too: it is RAG rated (red, amber, green), counting down the first 72 hours of those patients who have triggered a screening, so from here you can manage the CQUIN delivery alongside accessing patient-specific details from the system."
The right support, at the right time
It is can be a very distressful time for patients diagnosed with dementia who need to visit hospital. With so many people living with memory problems without a diagnosis, the software usefully prompts healthcare professionals to make relevant assessments for people with suspected dementia, while guiding them to the correct care pathway through referral to their General Practitioner (GP). Quicker referrals for the attention of healthcare professionals can lead to a higher quality of care, helping the patient and their carers to feel more comfortable that the condition is manageable.
The impact on the healthcare economy has been identifying signs of dementia or other cognitive conditions earlier, and relaying this intelligence back into the community. This integrated approach saw the screening of 417 patients in one month, with 46 patients identified to their GP for follow up - something the trust was unable to do before.
Underwood is keen to stress this isn't just a numbers game: "Using this system really contributes to the clinical care of the patient - it is not just here to report numbers, it is here to ensure quality care, driven through incentive, is being delivered to benefit patients.
"We will grow stronger relationships with primary care because we are providing GPs with simple, but useful information in our discharge letters, driven from a system that supports data collection at the front door - this meets our own ambitions to be a high quality dementia care provider and supports our work on integrating dementia care provision, which is really important to us across Cornwall."