UCLA Alzheimer’s and Dementia Care Program

uclaDuring my time in the US I had the opportunity to visit Los Angeles and more specifically the UCLA hospital campus to meet with Leslie Evertson (Lead Dementia Care Manager) and Dr Tan Zaldy (Medical Director) to hear more about their award winning program.

As with all of the services I have visited, I was drawn to the program as they offered something ‘extra’ for patients who are often more complex and in need of additional support. Having worked in a memory clinic for 6 months in the UK, I was in a good position to be able to compare and contrast the services provided in vastly different health care systems.

UCLA Alzheimer’s and Dementia Care Program accepts patients referred from their community team (family doctor/GP) with a diagnosis of dementia already in place. They are then seen for a lengthy assessment to review their current support need and plan for the future, which is not dissimilar from UK practice. Where the program does differ is in its provision of care coordination, education, carer support, liaison between community and specialist care, advance care planning and linkage to community resources.

The program has close links to the resources in the area such as the Jewish Family Service, ONEgeneration etc as well as organising support groups in the local area, for patients and their families. The service allows the care for that individual to be proactive, rather than reactive, with medication planning, advance care planning and open and on going discussion with the service users.

The most impressive project that the program coordinates is a Dementia Bootcamp. These run in the local community from 8am-5pm on a Saturday and have space for around 30 patients and family members. As well as offering the usual perks of food, respite and social connection, the bootcamp has sessions with occupational therapists, physiotherapists, clinicians, psychologists, marriage therapists as well as peer support groups giving individuals chance to tell their story and encourage learning. The idea of providing all of this specialist health education in such an open, supportive environment is very unique and gives those individuals and family members chance to have their voice heard and fosters learning and relationship building.

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Getting my head around health care systems, or at least trying.

confusingAfter having spent 2 weeks in Melbourne and visiting several primary care practices I would still find myself having to clarify exactly how things work. Having spent the entirety of my career thus far working for the NHS, and being a passionate supporter of it it took some time to get my head around how things work in Australia. Many of my conversations with different health care professionals would often digress to the nitty gritty of how the two systems compare, with each of us trying to comprehend anything but our known service.

Here are a few key differences I have learnt which dramatically effect both the way the public use primary care services and also the way GP practices serve their locality.

In Australia:

  1. Patients are not obliged to be registered with one GP, which can lead to doctor shopping.
  2. Health care is delivered as a mixed system of universal (public) health care and insurance (private) health care. Public health care is provided via Medicare, which subsidises most medical costs.
  3. Medicare pay scheduled fees for doctor consultations or procedure – this is around $36 and GPs can then choose to set their fees, with the patient covering the difference.
  4. Bulk-billing is when the doctor accepts the Medicare benefit (that’s 85 or 100 per cent of the Schedule fee) as full payment for the services rendered. Patients don’t have to pay the gap.

It goes without saying as with any health care system there are nuances, but the above differences do lead to the Australian GP services being more business focused.

Headspace Frankston – more than just a Youth Mental Health Centre

My next visit took me down to towards the Mornington Peninsula to visit Frankston, home to the largest of the Headspace services where I met Courtney to hear a little bit more about their service and the teams involvement in the Health Care Homes (HCH) program. They only had small numbers signed up to HCH program at this stage as consent had proven to be a sticking point for many of the youths, who really valued the confidentiality of the space. That said, the HCH program would offer department of health funding to a service which currently relies on the Headspace organisation, some primary health funding and individual tenders.

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Headspace is an organisation which began in 2006 and was born out of a need to plug the gap in services by providing tailored and holistic mental health support for 12-25 year olds. With a focus on early intervention they have an aim to change the trajectory of the youths attending the service and enabling them to better manage their difficulties. The organisation now has over 100 sites across Australia and remains a not-for-profit organisation.

Frankston Headspace sees over 1500 youths a year and is facing an increasing demand as state funded programs have declined and the pressures on A&E departments have increased meaning that the team find they are getting more and more referrals from clinicians, in addition to being a popular service for youths to self-refer to. They currently have four GPs, 6 counsellors, youth workers and nurses and they offer an all under one roof service. On speaking to Courtney, the idea is that this group are a difficult cohort to access, let alone to motivate to keep returning for appointments and so Headspace Frankston have streamlined how they operate.

All of the services that a youth may need to access have been huddled under one roof; they have access to a sexual health clinic, GP services (who complete their own pathology), drug and alcohol services, mental health services, group therapy, counselling, an early intervention psychosis service as well as youth programs and work and study services. They aim to get their patients seen by as many relevant allied health professionals as quick as possible, and it works. They find that individuals not only come back for their follow up, but they bring a friend for check ups, and so the case load grows. Last week they had totalled at 70 referrals.

I currently work with a Child and Adolescent Mental Health (CAMHs) service in London and it can often become convoluted when trying to patients to the different allied health services and patients can be left in the dark trying to navigate which professional they see for which complaint. This solves that. Secondly, due to the structuring of psychiatric services in the UK, there can often be a difficult transition period when a adolescent turns 18 years of age and is no longer suitable to be under the care of a CAMHS team but is often much closer in emotional maturity and disease progression those individuals in CAMHs as oppose to general adult services. In addition to this, many don’t then meet the criteria to be managed by an adult community mental health team leaving them without support at a very important life stage. This solves that.

Headspace Frankston offered a school in reach as part of a suicide prevention and postvention program. If a young person takes their life, Headspace take a team and visit the school which they attended as well as any sports of social groups to offer support and debrief for the people that were in close contact with the individual, in order to help with the processing of their grief. I thouheadpace buildingght that this was a fantastic intervention.

Finally, the building in which Headspace Frankston resides is testament to the interest of the youth being at its core. Set across one level, in a somewhat open plan layout the building was designed by a youth team paired up with the architects. In a bid to remove the clinical coldness of a health environment there was no white, all of the clinical rooms had colour, exposed brick and clever lighting, with as much natural light as possible. There were washing machines, showers and a food area the young people could access. The waiting areas were set up as to socialise those that wait in them, and the building had the overall feel of a cleverly designed art space that somehow managed to meet the privacy needs for its function.

An open-armed, wrap-around service – the First Step Program.

 

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After a mammoth 31 hours of flying, straight off the back of a set of night shifts, I arrived in Melbourne somewhat dazed. After a few hours to acclimatise, I picked myself up and took a stroll around the St Kilda area of Melbourne; home of the first organisation I had planned to visit – the First Step Program.

The area is a pretty one to walk around, with old mansions and coffee shop lined streets. Along with the rest of Melbourne, it has become a very expensive place to live and this has contributed to an increase in the prevalence of homelessness and the health related consequences of this.

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On approach, the First Step base is an unassuming, Victorian property just set back from the street. As I walked into the building, this homely, non-clinical feel extended into the waiting area which had a box piled high with pastries for those waiting. I was met by Patrick, the CEO of First Step who gave me a guided tour and filled me in on some on of the background to the organisation and later joined by Gayle, the Operations Manager.

 

First Step is a not-for-profit organisation and was founded in the year 2000. It was initially set up as an acute detox facility for those addicted to heroin and has evolved over the last 18 years to broaden its services to become more in line with a medical model, and cement itself as a valuable part of the local community. Patrick has been with First Step for 12 years and described the organisation as an “open-armed, wrap-around service” and I began to see why. All out of the one modest building they deliver management for hepatitis B and C, liver cancer, alcohol and drug addiction, physical and mental health, as well as providing in-house free legal services, art therapy, a women’s group, mental health bootcamp and a range of support for those who have experienced domestic violence.

First Step now manages a case load of over 5000 patients with complex needs and has a multidisciplinary team including GPs, a psychiatrist, mental health nurses, care coordinators, therapists and a legal team and is the largest opioid substitution provider in Victoria. The moment I walked into the building and met with the team at First Step it felt like a warm place, with enthusiastic and motivated staff driving it forward and seeking out new and necessary programs that they could offer. First Step have found that patient’s are engaged to keep coming back to have their holistic needs met when this is often not the case for this patient group due to the way primary care services are set up in Australia. It makes such sense to have a one-stop-shop for patients who may not have the means or support to make it to multiple appointments, with multiple agencies, across multiple locations and as a result often disengage from follow up. To highlight how First Step operates, and how it feels a part of the community, I would like to include a case vignette passed on to me by Gayle.

The previous week a man had been collapsed on the tram tracks and was found by a local lady and her two children. She helped him to his feet and drove him round to the First Step door at 5pm on a Friday evening. The man had a psychotic illness and multiple physical health problems. He was seen by a GP, the nursing team and supported to stay at home over the weekend before seeing a psychiatrist and receiving legal aid the following Monday.

The First Step Program are doing a fantastic job at delivering wrap around care to patients with complex health needs and I would like to thank Patrick and Gayle for taking the time to show me their work.

Follow my trip from Melbourne to California as I look into the different approaches adopted for looking after individuals with complex physical and mental health needs.

I will be focussing on the ongoing trial of the Health Care Homes model in Australia and the pros and cons of such an approach, and comparing the use of similar models in the US and the UK; the Patient Centred Medical Home and the Primary Care Home, respectively. Along the way I will be trying to visit both general practices and community mental health services who who are offering something extraordinary.

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