Developing a 3Ds Clinical Framework in a Community Integrated Team

• To develop a clinical framework that promotes and drives evidence-based practice by bringing together relevant NICE guidelines (Dementia, Delirium and Depression)
• The framework aims to ensure that decision making processes are based on best practice and the available evidence, being compliant with the relevant NICE guidelines, and Deteriorating Patient Guidelines.
• To promote parity of physical and mental health
• To develop a framework that was both patient-centred but also service focussed and accessible. That the framework was achievable and accessible for staff working in the integrated and nursing and therapy Neighbourhood Teams.
• To address the variation in quality of care delivery and planning offered to patients living with dementia in a community setting,
• To ensure that the clinical decision-making process is based on best practice and available evidence.
• To improve the diagnosis and treatment of delirium.
• To introduce proactive care planning for those who be at risk of developing delirium.
• To develop and introduce SystmOne (electronic record) templates and evidence-based assessments to support the desired change in practice.

Our Initial step was to understand the problem we were trying to solve. We conducted a series of audits against NICE guidelines and combined these with findings from complaints and investigations. In order to ensure engagement we held a series of workshops with clinical staff and focus groups. Both registered and unregistered staff were consulted as part of the information gathering process.

Feedback from patients and carers though the incident reporting and complaints process was collated.

The main themes from consultation were:

• A large variety in the standard of care delivery and knowledge across teams and staff groups
• Lack of knowledge regarding management of pain and behaviour for patients living with Dementia
• Knowing the person/personalised care
• Communication of decisions
• Delays in discharge from hospital or decision to admit when patients could be supported at home.
• Management of ‘acute confusion’
• Diagnosis and management of delirium
• Prevention of delirium and identification of risk.
• Recognition last days of life for patients living with dementia

Research shows that on average 7 out of 10 people living with dementia do so alongside other medical health issues including high blood pressure, heart disease, stroke and diabetes. We recognised that patients referred to the Neighbourhood Teams are not referred primarily due to a diagnosis of Dementia/Depression however in line with evidence a significant proportion of patients under the care of the Neighbourhood Teams have diagnoses of Dementia and/or Depression and are at risk of Delirium.

The framework was developed to provide best practice guidance on principles of care delivery. Whilst the main function of our Integrated Neighbourhood Teams is to provide care and case management for people who are elderly, frail or have multiple long-term conditions, the framework acknowledges that dementia, delirium and depression are all life changing conditions that are particularly common in these patient groups, and need to be given parity when working with patients and carers.

The Leeds Approach is to support clinicians to have better conversations with people who live with long-term conditions, based on agreeing goals and actions. This approach underpins the framework by embedding personalised and patient-centred care into all of the quality standards.

The project was co-produced with staff and clinical leadership throughout as our major stakeholders. Partner organisations and commissioners were also consulted and updated as the project progressed.

We wanted to take the six relevant NICE clinical guidelines related to people living with dementia, delirium and depression and bring them together to develop best practice standards in the form of a Clinical Framework which consisted of:

• Clinical Standards for dementia, delirium and depression
• A Delirium Pathway for prevention, recognition and treatment of delirium
• The introduction of a standardised assessment for delirium, using the Cognitive Assessment Method (CAM) on our electronic patient records
• Development of a delirium risk assessment screen based on NICE guidance
• Development of a dementia template to aid better care planning and delivery
• Delirium training package

The implementation of the 3Ds Clinical Framework has enabled our Integrated Neighbourhood Teams to identify key risks, signs and symptoms associated with all three conditions in an effective and timely manner this is evidenced by provision of appropriate prevention, assessment, support and treatment.

To engage further with frontline staff ensuring maximum potential for buy-in from clinical front-line staff we ensured the organisation’s statutory and mandatory Dementia one day training incorporated the same 3Ds standards of care delivery.

The training uses group activities and simulation experiences to facilitate embedding of the frameworks into everyday clinical practice. The frameworks were designed to condense a range of NICE guidelines into practical standards front-line staff can follow to ensure they are providing true evidence-based interventions for people living with dementia. We also had the clinical frameworks printed into shortened A5 diary sized prompt cards for clinicians to carry with them therefore having to hand best standards of care delivery.

An essential step in the implementation of the framework was the development of SystmOne templates to enable staff to efficiently record interventions as well as to prompt a high standard of risk assessment and documentation.

The frameworks provide front-line clinicians with set standards for care delivery and practical steps to take to ensure person-centred care is being provided. They also provide clinicians with knowledge and guidance on early identification of delirium, to enable quicker treatment and prevent possible avoidable hospital admissions.

Increasingly if able delirium is being treated in the community enabling patients to remain in their own homes. The clinical frameworks have been referenced in the establishment of a community virtual ward model. We are still in the early stages of implementation and embedding.

Initial audit results and feedback from stakeholders have indicated a positive impact on the standard of care provided. Longer-term this will hopeful able signs of delirium to be identified early for treatment in community settings rather than hospital admission, saving on hospital inpatient costs, as well as distress to people living with dementia from change in environments. Staff have evaluated the 3Ds frameworks and accompanying training highly:

• “My approach towards people will be affected both personally and professionally”
• “Better patient engagement = better outcomes”
• “Will feel more comfortable in supporting patients living with dementia”
• “I will approach patients with dementia, depression and delirium with a different approach. I will be able to deal with patients with a more constructive and positive manner”
• “We have a better understanding of dementia and how to respond in difficult situations”
• “I feel like I am now able to provide more person-centred care to a patient with dementia understanding their perception”.

Staff want to deliver high quality evidence-based care, they just needed the tools and a clinical framework to enable them to incorporate the various NICE guidelines into their everyday clinical practice.

To embed a new way of working takes a multi-action approach. The full 3Ds clinical frameworks are a detailed version of the care standards and principals. The small prompt cards helped front-line staff have an aid memoir of how to embed the clinical frameworks on a day-to-day basis in their care delivery.

The face-to-face one day training allowed clinicians to develop practical skills and knowledge-base to be able to understand the rational for the frameworks, and why person-centred care makes such a difference to people living with dementia, ensuring their needs are appropriately identified and met within their own home setting, preventing avoidable hospital admissions and associated distress and costs.

Dementia training was available before we developed the clinical frameworks, and although staff found the dementia training useful, they found it difficult to transfer the learning and evidence-base around best practice to their everyday clinical care.

The clinical frameworks and associated SystmOne templates have provided an accessible opportunity for clinicians to embed best practice into day to day care delivery. If we were to do it again, we would have develop and launched the clinical frameworks earlier at the same time as the training taking place to help tie it all in together.