Nurse-led dementia liaison service acts as bridge to secondary care
GP practices in Stoke-on-Trent and across North Staffordshire are benefiting from the support of dementia primary care liaison nurses as part of a new community service. Introduced in September last year, the nurse-led service, ran by North Staffordshire Combined Healthcare NHS Trust, acts as a bridge between primary health care and secondary mental health services
GP practices in Stoke-on-Trent and across North Staffordshire are benefiting from the support of dementia primary care liaison nurses as part of a new community service. Introduced in September last year, the nurse-led service, ran by North Staffordshire Combined Healthcare NHS Trust, acts as a bridge between primary health care and secondary mental health services.
Before the dementia primary care liaison service had been introduced, patients with dementia were required to attend one of the trust’s hospital-based memory assessment service clinics for regular reviews. Now, patients with confirmed diagnoses of dementia, who are stable and established on their medications, can be reviewed in the community as part of the service’s nurse-led memory clinics.
The band 6 nurses have established clinics in their allocated GP practices, which enables patients to receive care and support closer to home in a familiar environment. Patients can be seen at home or in nursing and residential care homes, if this is more convenient. Patients are reviewed every six months as part of the memory clinic service.
‘We have worked with the hospital memory clinic to set up a protocol to provide the service in the community,’ says Stoke-on-Trent’s dementia primary care liaison team leader Linda Simcock.
‘Care plans are created with patients and their families at their last secondary care memory clinic appointments. The patients are then informed that the service will be provided closer to them and that they will no longer need to attend hospital for their reviews.
‘Each patients is given a care plan, and the name and contact details of the nurse who will pick up his or her care in the community. We let the patients know that their nurses will be in touch to arrange their next reviews in six months’ time, but that they can contact the nurses at any time before then if they have any questions.
‘We hope that by bringing the review service into the community, we will free up hospital memory clinic appointments to enable faster assessment and diagnosis for other patients.’
The memory review covers all aspects of patient wellbeing, including appetite, mood changes and mobility, and identifies any social issues patients may have.
Initial assessments are carried out by GPs or nurse practitioners. Teams ask the patients to undertake the clock-drawing test so that they can assess memory changes. The test is repeated every six months to monitor patients for signs of deterioration.
A team of three dementia primary care liaison nurses provide support at all GP practices in Stoke city centre. In North Staffordshire, a team of two dementia primary care liaison nurses provide support to 14 GP practices in the Newcastle-under-Lyme and Staffordshire Moorlands areas as part of a one-year pilot. The team hopes that the North Staffordshire service will continue after the pilot period has ended.
The Stoke service has been commissioned by Stoke-on-Trent Clinical Commissioning Group (CCG), while the North Staffordshire pilot is being funded by North Staffordshire CCG.
‘We support GPs with their annual quality outcomes framework (QOF) dementia reviews,’ says North Staffordshire’s dementia primary care liaison nurse Emma Vause. ‘This holistic assessment covers everything from patient mobility and cognition to nutrition. From the results we can look at whether there is anything that must be addressed and we can formulate new care plans for patients.
‘The review also helps us to assess whether patients would benefit from additional support, for example from social services or from voluntary organisations such as Age UK or local dementia support charity Approach.
Ms Vause continues: ‘Alternatively, we may identify a patient who has deteriorated and must be seen by the hospital memory clinic team. We can also review physical health concerns with the patient’s GP.
‘The memory clinic reviews are carried out with GPs and at the same time as patient QOF dementia reviews if both reviews are due at the same time and the patient prefers them to be undertaken simultaneously,’ says Ms Vause. ‘We aim to reduce the number of practice visits for patients where possible.
Urgent response calls
‘We also handle urgent response calls from GPs and practice nurses. If patients’ dementia requires urgent review by a community psychiatric nurse, they can contact us and, if they are in care homes, we will go out to see them within 30 minutes. If patients are in their own homes, we contact their carers or nominated persons to get assessments.
‘In each case, we undertake an initial triage assessment to get immediate signposting in place and enable the GP to deliver treatment faster. This works well and means the practice does not need to contact the hospital memory clinic to arrange for someone from the team there to carry out a triage.’
The relationship between each practice and its allocated specialist nurse depends on how the practice prefers to operate. In some cases, GPs want to undertake joint reviews with the nurses; in others, the specialist nurse will carry out QOF dementia reviews alongside practice nurses.
‘The aim of the service is to provide support and increase understanding of how to manage dementia in primary care,’ says head of North Staffordshire Combined Healthcare NHS Trust’s neuro and old age psychiatry directorate Jane Munton-Davies. ‘The teams have targets for care plans being reviewed in line with the QOF.’
One of the benefits of the dementia primary care liaison nurse service is the continuity of care it offers patients. Patients who use secondary memory services are seen at dementia reviews by one of a number of practitioners, but those who attend practices in Stoke and the pilot areas in North Staffordshire are always seen by named dementia primary care liaison nurses.
‘Our service offers patients, carers and families convenience and reassurance,’ says Stoke-on-Trent’s dementia primary care liaison nurse Anna Dunn, who is allocated to 15 general practices across the south of the city.
‘They are happy about the service, [partly because] they have someone they can talk to. Many families do not know where to turn when a loved one is first diagnosed with the condition.
‘We have a direct line for patients and carers to contact us if they require any advice or support. We can help with any issues, questions or concerns, and provide a whole package of support to ensure all their needs are met. As we continue to regularly review patients, this will also help to build relationships and trust.’
A case study involving Ms Dunn is set out below.
The nurse-led service provides a ‘much-needed’ support line to patients, says Stoke-on-Trent’s dementia primary care liaison nurse Anna Dunn.
She says: ‘A patient’s wife called and was distressed, saying that her husband was not eating or drinking as part of his condition. She did not know much about dementia, so I went out to see her the following day and explained all about her husband’s diagnosis and what to expect in the future.
‘I explained the reason her husband was not eating or drinking was due to him having swallowing difficulties. I also referred the patient to a speech and language therapist to have a quick review, and advised the patient’s wife what is out there to help, such as carers support groups. I made sure she had my contact number and left her with a few information leaflets that we provide. She said she would not have known what to do if this service was not available.
‘Having a nurse to contact in times of need really does makes a difference. Patients and carers feel more supported, just having that direct contact with us.’
The service is an extension of the trust’s care home liaison service and staff in the two services work closely together. The role of some of the dementia primary care liaison nurses also encompasses care home liaison.
‘The care homes that are covered by the GPs in our area are also covered as part of our care home liaison nurse role,’ explains Ms Vause. ‘This includes patients who present with behaviour or mood difficulties and any sort of mental health or psychiatric need.
‘We work with GPs, care home staff and consultants to adjust treatment or management plans to try to reduce hospital admissions.’
The dementia primary care liaison nurses provide a valuable service to GP practices. Feedback from practice staff, including GPs and practice nurses, has been positive.
The nurses form a link between primary and secondary mental health services, and can advise on medication and side effects. They also liaise one day a week with hospital consultants to review patients and receive advice.
‘If there are concerns about a patient, practices can call on an identified additional member of staff, the dementia primary care liaison nurse,’ says North Staffordshire’s dementia primary care liaison team leader Rachael Birks.
‘Practice staff have got to know their nurses and share information easily. If a GP or practice nurse has a query about a patient, they can pick up the phone and speak to their specialist nurse.
‘We have removed the need for general practices to make direct referrals to hospital because they have allocated nurses with expertise on hand.’
Julie Penfold is a freelance health writer
For further information about the dementia primary care liaison teams, call 0300 123 1535 extension 4754