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Norfolk Admiral Nurse Pilot Evaluation Report

Authors:

Abstract

Evaluation report in relation to a pilot Admiral Nurse Service in Norfolk using mixed methods data collection
Norfolk Admiral Nurse Pilot
Evaluation Report
July 2014
Zena Aldridge Admiral Nurse Lead Registered Mental Health Nurse Dip HE, MA
Nicola Findlay Registered Occupational Therapist BA, MSc
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TABLE OF CONTENTS
i Foreword ............................................................................................... 5
ii Acknowledgements ........................................................................... 7
1 Introduction ......................................................................................... 8
2 The Admiral Nurse Pilot ..................................................................15
3 Evaluation ........................................................................................... 17
4 Results from the Pilot ......................................................................22
5 Cost/Benefit Analysis .......................................................................32
6 Conclusion ..........................................................................................38
7 Appendix .............................................................................................40
8 References .......................................................................................... 47
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FOREWORD i
Partnership working has been key to the success so far in securing Norfolk’s first
Admiral Nurses. Numerous organisations have been involved at various levels of
the process, from both the third and statutory sectors. It has been important to
balance the interests and needs of these stakeholders while keeping the project
on course to achieve its overall goal, which is the establishment of a full and
effective Admiral Nurse service for the carers in Norfolk who provide so much
for people with dementia.
There was initially, as ever, an issue regarding the start-up funding and despite
pressure from various organisations, meetings and good intentions, it was not
until Dementia UK approached Norfolk and Suffolk NHS Foundation Trust (NSFT),
that there was the necessary seed funding to commence the project. A Project
Group was quickly established and tasked itself with establishing the best way to
implement the Admiral Nurse role into the Norfolk dementia services. Members of
the Group contributed their knowledge, experience and resources as well as their
vision for Admiral Nurses, to the process. This resulted in a pilot project being located
in the Mid Norfolk area. The charitable funding was enhanced by a contribution
from NSFT in order to increase the number of Admiral Nurses to three. The Admiral
Nurse Team was then structured with a lead Admiral Nurse role (employed by Age
UK Norfolk) and two team Admiral Nurses (employed by NSFT).
The work then turned to more detailed operational issues to ensure the working
relationship between the 3 main implementation stakeholders was as effective
as possible, at this stage an Operational Group was established to include
Dementia UK, Age UK Norfolk and NSFT Operational Managers. A Memorandum of
Understanding, Information Governance Agreements and Operational Policy were
developed and agreed. This group continues to meet regularly to ensure operational
matters are addressed and importantly the evaluation of the Admiral Nurse Project
is undertaken appropriately.
Gary Hazelden
Partnership Lead
Norfolk and Suffolk NHS Foundation Trust
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ACKNOWLEDGEMENTS ii
We would like to thank all of the carers and professionals that took
part in this evaluation by giving their time to participate in interviews
and completing questionnaires.
Thank you to those who contributed information to enable analysis of
the data that was gathered.
We are grateful to the partnership that has been developed between
Age UK Norfolk, Dementia UK, Norfolk and Suffolk Foundation Trust and
The Peoples Health Trust without whom the Admiral Nurse Pilot would
not have been possible.
Special thanks to Nicola Findlay, who has carried out this evaluation in
a voluntary capacity, and without whom it would not have been possible
to achieve such an in depth analysis of the pilot to date.
Zena Aldridge - Admiral Nurse Lead
Age UK Norfolk
300 St Faiths Road
Norwich NR6 7BJ
t 01603 785202
e zena.aldridge@ageuknorfolk.org.uk
Nicola Findlay – Occupational Therapist
Open Arms Support Services Ltd
77 Newmarket Road
Norwich NR2 2HW
t 07502 313891
e oass.norfolk@gmail.com
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INTRODUCTION 1
1.1 Overview of the Evaluation
The evaluation report has been compiled by Zena Aldridge, Admiral Nurse Lead
and Nicola Findlay, Occupational Therapist, MA and edited by Kate Rudkin, Head
of Development and Operations, Age UK Norfolk.
A Pilot Project to trial the esteemed Admiral Nurse Service format commenced
on April 2013 in the mid Norfolk area serving seven GP surgeries.
The evaluation study has investigated the effectiveness of the Admiral Nurse
Service against agreed outcomes with both quantitative and qualitative data used
to produce relevant data for analysis.
1.2 Aim of the Evaluation
The aim of the evaluation is to ascertain what, if any, impact the Admiral Nurse
Service has had within the pilot area of Mid Norfolk. The following key questions
have been identified to explore:
Q1 Have Admiral Nurses improved the physical, emotional and mental
well-being, of carers of people with dementia?
Q2 Has the presence of Admiral Nurses impacted on diagnosis rates of dementia?
Q3 Has the presence of Admiral Nurses had a positive impact on other
professional’s caseloads, and improved their ability to manage the care
of people with dementia and their carers more effectively?
Q4 Have the interventions offered by Admiral Nurses reduced admissions
to Acute or Mental Health hospital beds?
Q5 Have the interventions offered by Admiral Nurses reduced/delayed
admissions to Residential and Nursing care for people with dementia?
Q6 Have the interventions offered by Admiral Nurses improved outcomes
at End of Life for people with dementia and their carers?
Q7 Do Admiral Nurses offer value for money in achieving Health and
Social Care targets and legislative requirements?
1.3 Overview of an Admiral Nurse
Admiral Nurses are registered nurses specialising in dementia. Admiral Nurses
work with family carers and people with dementia, in the community and other
settings. Working collaboratively with other professionals, Admiral Nurses seek to
improve the quality of life for people with dementia and their carers. They use a
range of interventions that help people live positively with the condition and
develop skills to improve communication and maintain relationships.
Admiral Nurses work holistically with families, addressing the needs of the family
carer(s) as well as the Person with Dementia (PWD). Their aim is to empower family
carers and encourage problem solving approaches. All Admiral Nurses hold a
nursing qualification, are trained to meet the mental health needs of family carers
and are able to provide psychological support to avoid crisis and breakdown.
1.3.1 The role has two main functions:
Clinical casework with carers of people with dementia (PWD). This may be
long or short term depending upon need.
• Consultancy work with other professionals.
Nursing interventions are based on a research based stress management model,
encompassing carers’ needs which cause or are likely to cause stress. These can
be broadly summarised as information needs, emotional support needs and skill
needs (coping with problem solving). Admiral Nurses assist, support and empower
carers by providing:
Assessment of physical and mental health of the carer and the PWD and
subsequent meeting of those needs identified.
Enhancing the level of carer understanding in relation to diagnosis, symptoms,
behaviours, treatments and approaches to care.
Facilitating access to professional care and resources available to the
carer and PWD.
Admiral Nurses also offer a consultancy role to other professionals by providing:
Education and training on any aspect of dementia for voluntary groups and
professionals.
Acting as a resource for written and verbal information covering all aspects of
dementia care.
1.3.2 The philosophy of the service is:
Carers and family members will cope better if they have a full understanding
of the condition of the person with dementia. The Admiral Nurse will therefore
provide education, information, advice and support to carers on all issues
surrounding dementia care.
The Admiral Nurse:
• believes that there is a need to raise awareness of the needs of people with
dementia and their carers’ in order to promote equality and respect for the
personhood of those who have dementia and those who care for them.
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will use opportunities to promote these issues within care settings and at a wider
level within society.
will offer education and support within their catchment area and will provide a
consultancy service as a nurse specialist.
believes in the benet of multi-disciplinary and multi-agency working in the
complex field of dementia care.
will work collaboratively with other disciplines to improve the quality of care
for the carer and the person with dementia.
believes that carers and people with dementia must be respected as individuals.
They have a right to confidentiality, dignity and privacy. They also have legal and
civil rights under the NHS Constitution (2013) and Human Rights Act (1998) to be
treated in a fair, open, honest and flexible manner.
believes in equality of service provision and acknowledges the diversity of
carers. We welcome all carers regardless of age, ethnicity, disability, religion
and sexual orientation.
1.4 The National Picture – Dementia and Carers
There are around 800,000 people in the UK with dementia and an estimated
670,000 family and friends acting as primary caregivers to a person with dementia.
The current cost to the NHS, local authorities and families is £23bn per year: this is
expected to grow to £27 billion by 2018 (Alzheimer’s Society 2012). The Alzheimer’s
Society (2012) estimates that carers for people with dementia save the UK over £8
billion per year.
Willis and Solliman (2001) and Moise et al (2004) cited by The Carers Trust (2013)
states that:
‘The majority of people with dementia are cared for at home by a relative or
friend. The average age of (unpaid) family carers is between 60 and 65 years,
and many are much older. Caring for a person with dementia can be very
different from caring for people affected by other types of illness or disability,
because of the complex, unpredictable and progressive nature of the illness.
Carers of people with dementia are likely to have higher than normal levels of
stress, and report higher levels of depression than carers of other people.’
Further evidence of the need to support carers can be seen within the findings
of a report by the Princess Royal Trust for Carers (2011) which found that:
Two thirds (66%) of older carers have long term health problems or a disability
themselves
One third (33%) of older carers reported having cancelled treatment or an
operation they needed due to their caring responsibilities
Half (50%) of all older carers reported that their physical health had got worse in
the last year.
More than 4 out of 10 (>40%) older carers said that their mental health had
deteriorated over the last year.
It should not be forgotten that some carers of people with dementia are much
younger. They could be in a caring role for a parent or grandparent, or caring for
a partner who has an early onset dementia prior to the age of 65. This can cause
differing issues for the carers that need support in addressing e.g. employment,
caring for younger children or accessing education.
1.5 The Norfolk Picture
Data published in Norfolk Dementia Needs Assessment 2010 identified that:
‘Current data predicts increases in the numbers of people being identified with
dementia in the future. Due to the ageing population, this will be pronounced in
districts with older populations and will also depend on changing ethnic mix of
successive ageing cohorts and local and personal socioeconomic circumstances
for residents. NHS Norfolk (2010) is estimated to have 11,789 dementia sufferers,
rising to 15,590 by 2020. In NHS Great Yarmouth and Waveney, 3,470 current
sufferers will rise to 4,603 by 2020 according to the projections used.
Norfolk continues to have a relatively elderly age profile, with around a fifth
of the population aged 65 and over (20.8%) and one in ten aged 75 and over
(10.1%) (Mid-2008 population estimates, ONS).
People of pensionable age now exceed the under 16s nationally for the first time,
though in Norfolk there are currently 1.4 pensioners for every child under 16.
The latest Government (Office of National Statistics, ONS), projections for
Norfolk indicate that, based on recent trends, the population would increase
from 832,400 in mid-2006 to 1,058,000 in 2031, an increase of over 225,000
(more than a quarter) over the next 25 years.
People aged 65-74 and aged 75 and over would increase by 56.0% and 94.0%
respectively by 2031.
Norfolk has a different population age structure compared to England.
It has a higher than average proportion of older people in its population
compared to the England average. There is also longer life expectancy in
Norfolk compared to England. Age is an indicator of the likelihood of
developing dementia therefore Norfolk is likely to have a higher incidence
of the disease than England as a whole.
This is demonstrated in the chart overleaf:
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NHS Norfolk (2010)
A further Norfolk Dementia Health Needs Assessment is currently being undertaken
by Public Health which is due for publication in August 2014 and will offer updated
demographic data that was unavailable for the purpose of this evaluation.
1.6 National and Local Drivers
1.6.1 The National Dementia Strategy 2009 (NDS): was a response to the
challenge that dementia presents to the Health and Social care system and to the
widespread recognition that existing services are already inadequate, let alone
sufficient to meet that challenge. The strategy identified 17 key objectives to be
implemented in all localities.
1.6.2 The Operating Framework for the NHS in England for 2012-13 (2011):
clearly reiterates Government’s commitment to implementation of the NDS.
1.6.3 Norfolk Dementia Strategy: ‘Transforming the quality and experience of
dementia care for the people of Norfolk. A joint commissioning strategy 2009-
2014’ was a response to the NDS; a collaborative local document was produced
by Norfolk County Council, NHS Norfolk and NHS Great Yarmouth and Waveney,
the Primary Care Trusts (PCT’s) at the time. This focussed on 12 of the objectives
from the NDS that related directly to provision of services locally for people with
dementia and two that underpinned local action on workforce development and
joint commissioning between public sector organisations in order to ensure that
dementia services for the future are more ‘person-centred.
1.6.4 End of Life Care Strategy (DOH 2008): identifies the need for the support of
family carers. Three key principles that should apply to carers of people approaching
the end of life were identified as:
Carers are central to the team that cares for somebody at the end of life and they
should be treated as ‘co-workers’ with the health and social care team;
Carers have their own needs. Those providing a substantial amount of care on a
regular basis are entitled to a community care assessment by their local authority;
and
The condition of the person who is cared for should not affect how the carer is
treated, or the services the carer may be able to access. ‘
It went on to identify that:
‘It should be recognised that not all carers are family members and that not all
family members are carers. Family members may have needs for psychological
and social support that are separate from those of the carer or the person who
is being cared for. It should also be recognised that the carer’s needs and wishes
may conflict with those of the dying person and perhaps the rest of the family
and will need to be managed carefully.’
1.6.5 The Carers Strategy (DOH 2008) envisaged that by 2018:
‘Carers will be respected as expert care partners and will have access to the
integrated and personalised services they need to support them in their caring
role;
• Carers will be able to have a life of their own alongside their caring role;
Carers will be supported so that they are not forced into nancial hardship by
their caring role; Carers will be supported to stay mentally and physically well and
treated with dignity.’
1.6.6 The Prime Minister’s Challenge (DOH 2012) identified that:
‘Dementia is one of the biggest challenges we face today – and it is one
that we as a society simply cannot afford to ignore any longer. We have made
some good progress over the last few years, but there’s still a long way to go.’
As a result NHS England has now set the first ever ‘national goal’ for diagnosis
rates, calling for two-thirds (67%) of people with dementia to have a formal
diagnosis by March 2015. (Currently the average diagnosis rate in Norfolk is
42% based on figures from 2012-2013 with significant variance within both
CCG’s and GP practices).’
1.6.7 Norfolk’s Health and Wellbeing Board has identified Dementia as one of the
three priorities for the County during 2014-15.
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1.6.8 The Care Act 2014
This recently enacted Bill requires fundamental reform of 60 years of care
legislation. It sets out the general responsibilities of local authorities towards all
people: the well-being principle underpins the entire legal framework with Universal
obligations towards all local people:
1. arranging services, facilities or taking other steps to prevent, reduce or delay
needs for care and support.
2. information and advice to help people understand the care and support
system, access services and plan for the future.
3. promoting diversity and quality in the market of providers so that there are high
quality services to meet people’s choices.
There is a requirement to work collaboratively and cooperate with other public
authorities, including duty to promote integration with NHS and other services
(including housing).
Importantly it includes the first right to support for carers – on the equivalent basis
to the people they care for, and with clarity around how meeting those needs may
include care directly for the person cared for.
THE ADMIRAL NURSE PILOT 2
2.1 Scope of Current Service
The service covers the following 7 surgeries in South Norfolk for casework which are:
• Mattishall Surgery (incorporating Lenwade surgery)
• North Elmham Surgery (incorporating Swanton Morley Surgery)
• Orchard Surgery (Dereham)
• Shipdham Surgery
• Theatre Royal Surgery (Dereham)
• Walker- Gregory Practice (Toftwood)
• Watton Medical Practice
There are currently 3 Admiral Nurses working in a defined area within South Norfolk
Clinical Commissioning Group (SNCCG).
2.2 Resources
Initially, a Band 7 Admiral Nurse Lead post was created with funding from the
Peoples Health Trust and hosted by Age UK Norfolk. This was supported through the
partnership that was developed between Age UK Norfolk, Dementia UK and NSFT.
The Lead post commenced in April 2013.
Subsequently, NSFT supported the pilot further by providing 1.65 WTE Band 6
nurses in June 2013 which has enabled a casework model to be piloted and they
have been committed to the pilot until it comes to an end in April 2015.
2.2.1 Admiral Nurse Lead (Band 7)
The Band 7 role is one of professional navigation acting as Locality Lead responsible
for managing and coordinating an inter-agency approach to the management of
clients through the cognitive impairment pathway. The Lead has a comprehensive
knowledge and understanding of the Norfolk Dementia Strategy, and associated
pathways and has formed effective working relationships with all pathway service
providers and stakeholders.
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The Lead has a strategic overview of dementia services and has clinical input into
developing services relating to the provision of support for people with dementia
and their carers.
The Lead also acts as clinical lead for the current Admiral Nurse Service and carries
out all triage assessments to ensure that clients are accessing the appropriate
resource within the dementia pathway.
2.2.2 Admiral Nurses (Band 6)
The Band 6 Admiral Nurses work directly with carers of those with dementia to
enable them to navigate through the dementia pathway.
2.3 Access to the Service
The Admiral Nurse Service operates an open referral system. Referrals are welcome
from professionals, voluntary organisations and self- referral.
Referrals are triaged by the Admiral Nurse Lead. The following criteria must be met:
• The person cared for has a diagnosis or suspected diagnosis of dementia
• The carer or PWD must live in the pilot area.
• The carer has consented to the referral being made.
2.3.1 Examples of appropriate referral are:
• When there is conict between the needs and desires of the carer and PWD.
When the carer has difculty understanding or coming to terms with
the diagnosis.
• When there is emotional support or practical strategies required by the carer.
• When the carer needs practical skill training, information and advice.
When the carer nds it difcult to make choices or decisions such as: consideration
of long term care or acceptance of help.
• When other workers need advice training or support.
• To help the carer make decisions about end of life care.
• When the carer needs help to express choices and needs.
• When there is conict within the family about the care of the PWD.
• To offer support and guidance at the point of diagnosis.
• To act as an advocate for the carer in liaison with other organisations and services.
2.3.2 Examples of inappropriate referrals:
Crisis management for PWD–Referrals will be redirected to appropriate
resources- e.g. Community Mental Health Teams, Dementia Intensive Support
Team, Social Services.
• When the primary need is for the PWD and not the needs of the carer.
• Continuing Healthcare (CHC) Assessments for the PWD.
EVALUATION 3
3.1 Research Design
This evaluation utilised a mixed methods (Tashakkori & Teddlie, 2003) design,
which is a procedure for collecting, analysing and ‘mixing’ both quantitative and
qualitative data, to understand a research problem more completely (Creswell,
2002). The rationale for mixing is that neither quantitative nor qualitative methods
are sufficient by themselves to capture the trends and details of the situation,
such as the complex coping mechanisms employed by the carer of someone with
dementia and the implication that this has on services. When used in combination,
quantitative and qualitative methods complement each other and allow for more
complete analysis (Green, Caracelli, & Graham, 1989, Tashakkori & Teddlie, 1998).
(For further information regarding methodology see Appendix).
This evaluation utilised a convergent design, where both qualitative and quantitative
strands are conducted separately, yet concurrently and merged at the point of
interpretation. Equal priority is given to each strand and it ensures a more complete
understanding of the impact that the Admiral Nurse Service has had on the families
that access support and on the wider medical community.
Whilst this evaluation aims to establish and comment on benefits to both the
carers of someone with dementia and the professionals who work with them, it is
important to reveal if the benefits are purely therapeutic or if there is a financial or
other benefit.
3.2 Research Permission and Ethical Considerations
Ethical issues were addressed during each strand of evaluation. Whilst no
formal ethical approval was necessary (i.e. from COREC), the ethical guidelines
established by this governing body were followed. Participants were given detailed
information on the nature of the evaluation by their Admiral Nurse and the nature
of their involvement with the study. They were then given the opportunity not to
participate. The nature of the evaluation was re-explained to the carers over the
phone prior to completing the semi structured interview. They were given another
opportunity to opt out of the investigation. It was made clear to the carers that
the support they received from the Admiral Nurses would not alter based on the
information they gave, or if they chose not to take part in the questionnaire. In
order to increase the evaluation’s objectivity, the information given to the carers
was read from a script.
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The Researcher was independent from the Clinical Commissioning Groups, Norfolk
and Suffolk Foundation Trust and Age UK Norfolk. The Researcher was given an
honorary contract with Dementia UK, allowing access to relevant data in order to
contact Admiral Nurse service users. This ensured that the evaluation was carried
out whilst adhering to the Data Protection Act (1998).
Participants were assigned fictitious names for use in their description and reporting
the results. The anonymity of professionals who completed the peer review
questionnaire was protected by numerically coding each returned questionnaire
and keeping the responses confidential unless they had agreed to be identified. All
study data, including the survey electronic files, interview tapes, and transcripts, is
stored in locked metal filing cabinets in the Researcher’s office and will be destroyed
after a reasonable period of time. Participants will be told that summary data will
be disseminated to the professional community, but in no way it will be possible to
trace responses to individuals.
3.3 The Role of the Researcher
The Researcher’s involvement with data collection in the two phases of this
evaluation is different.
In the qualitative phase, the Researcher conducted the questionnaires by telephone
and analysed the data. There is no connection between the Admiral Nurses and the
Researcher, and the Carers involved in the study and the Researcher. This ensures
that there is a limited potential for bias (Locke, Spirduso & Silverman, 2000).
In the quantitative phase, questionnaires, designed by the Admiral Nurse Lead
in collaboration with Norfolk and Suffolk Foundation Trust’s Research and
Development Team, were issued to partner agencies including General Practitioners
and Social Workers. They were completed anonymously and the role of the
Researcher was to analyse the data using rigorous statistical analysis techniques.
The results were interpreted based on the established values for the statistical
significance of the functions.
3.4 Qualitative Strand
It is important to note that throughout this evaluation, there has been no reference
to how advanced in the trajectory the dementia is. This has been a deliberate
omission because the Admiral Nurses work with the carers directly and the patient
indirectly. Therefore the stage of dementia is academic and almost irrelevant,
as it is the carer’s ability to cope with the person with dementia’s condition that
fundamentally underpins the type of, and frequency of support that is required and
received from the Admiral Nurse. However, when interviewing carers, they would
often make reference to their perception of the severity of their loved ones illness,
saying things like:
‘Oh, he’s not that bad at the minute’ (Mrs Smith)
‘She’s gone downhill very quickly over the past few months’ (Mr Jones)
Carer’s seemed to define their role as carer with such statements and often
commented on how well or unwell their family member is, followed by a statement
about their ability to manage. For example; Mrs Smith went on to say:
‘So we’re doing alright and we’re only seeing her [Admiral Nurse] monthly,
which is fine.’
Mr Jones reported;
‘I need and value my time with my worker more than ever.’
As the carers’ ability to cope was seemingly defined by their perception of whether
their loved one was at the more advanced stage of dementia or being in the early
stages of the illness, these two categories will be used as a method of describing
the results of the qualitative strand of this evaluation.
It is essential to highlight that the definition of ‘advanced’ and ‘early’ are by no
means medical definitions and each carer, through the course of the interview,
naturally allocated themselves to one of these two groups.
3.4.1 Carers of those with more advanced dementia
It was possible to identify a small subgroup of those carers who identified
themselves as supporting someone with advanced dementia, and those individuals
whose family member had died. This was a small group, consisting of three
individuals. Others, whose relative was no longer living in the family home and were
instead residing in a care/nursing home, teetered on the edge of this sub group, not
as a consequence of their relatives health, but because their caring duties no longer
included practical and personal care.
Mr Avery talked about the transition from the marital home to a care home for is
wife as:
‘Being traumatic and emotional.’
He described himself as feeling:
‘Very fragile and helpless as he can no longer care for his wife as a husband
should do. She [wife] is in a no-man’s land, emotionally and physically. I’m just
waiting for her to pass on.’
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3.5 Participants
In the qualitative phase of the evaluation, thirty seven carers were asked
to participate in a telephone interview. Of these only one chose not to participate
and one was not contactable due to an invalid phone number. This was broken
down into:
• Twenty three spouses
• Eleven offspring of the patient
• One grandchild of the patient
Thirty three of the people asked were still in a caring role.
In the quantitative phase of the evaluation, twenty-eight percent of the one
hundred (100) questionnaires issued were returned; two had to be discarded
due to insufficient data. This was broken down into:
• General Practitioners
• Social Workers
• Nurses
The peer review questionnaires were issued to the professionals who use the
Admiral Nurse service.
Chart 1 demonstrates the professional disciplines of those individuals who returned
the questionnaires.
The inclusion and exclusion criteria for each strand of the evaluation can be seen in
table A.
Table A
Inclusion Criteria Exclusion Criteria
Qualitative 1) Clinical assessment
completed and an Admiral
Nurse allocated to the carer.
2) Open to the Admiral Nurse
service for at least one visit
by the Admiral Nurse.
3) Meets the criteria for the
Admiral Nurse Service (as in
section 2.3)
1) Clinical assessment
completed and no allocation
of Admiral Nurse.
2) Family has not received
support from an Admiral
Nurse for at least six months
prior to data collection.
Quantitative 1) Professionals asked to
complete the peer review
had to be within the correct
geographical area.
2) Professionals had to have a
good working knowledge of/
had used the Admiral Nurse
service.
1) Those professionals who are
not in the geographical area
that is entitled to an Admiral
Nurse service.
2) Those professionals who do
not work with individuals
experiencing dementia or
their families were not asked
to take part.
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RESULTS FROM THE PILOT 4
4.1 Referrals to the Norfolk service (June 2013-April 2014)
At the time of writing, in excess of 230 referrals have been received by the service
since commencement of casework in June 2013.
Dementia Advisors (DA) are employed locally by the Alzheimer’s Society but
primarily support the person with dementia. The Alzheimer’s Society has a role of
Dementia Support Worker (DSW) to support carers and PWD. Currently, in Norfolk,
they are commissioned through a Norfolk County Council contract to deliver
Information, Advice and Advocacy and therefore their primary role is not to offer, or
have the capacity to offer a 1-1 service for all of those seeking support.
It is arguable that some of the referrals that were received could have been
managed by a support worker with good knowledge of dementia care and did not
require the input of a specialist nurse, however the current commissioned provision
in Norfolk does not offer this service
Therefore, short term intervention was offered to these cases in order to ensure that
there was equity within service provision locally.
Those cases that did meet the criteria for the Alzheimer’s Society services were
referred appropriately.
Graph 1 below shows the number of referrals per month from June 2013–April 2014.
Chart 2 below demonstrates the route of referral and number per category.
There is an ongoing demand for the service and despite being in its infancy,
awareness of the service has been raised by promoting the service successfully
engaging both professionals and service users.
4.2 Evaluation of Outcomes
4.2.1 Q1: Have Admiral Nurses improved the physical, emotional and
mental well-being, of carers for people with dementia?
4.2.1.1 Relationship with the Admiral Nurses
The themes that emerged were different for those carers who considered their
family members to be displaying signs of advanced and early dementia, indicating
the different needs of the two discreet groups. There was one theme that was
consistent in nearly all the participants and this concerned the Admiral Nurses
ability to create an empathetic and supportive relationship very quickly.
Phrases such as ‘she [Admiral Nurse] is like a family friend’ and ‘I can tell her
[Admiral Nurse] things that I can’t tell anyone else’ were used repeatedly, even in
examples where contact was monthly and had only occurred a few times.
The service that the Nurses have provided has been a very personal and
client-centred service, and this has allowed the carers to feel that they have
been listened to and are getting their own needs met. As Mrs Warner stated:
‘They are the only service that is for me. All the other professionals
help my husband.’
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The very fact is that there are no other services that solely support the carers of
dementia patients, and also facilitates a therapeutic relationship between nurse
and carer.
4.2.1.2 Referral into the service and accessibility
Those carers who categorised themselves as supporting a relative with advanced
dementia were often unclear on how they entered services, reporting that “things
were a blur” or that they simply ‘weren’t sure: I was at my wits end.
Consistently, carers reported that their first contact with the Admiral Nurse
Service was at a point where they were feeling very stressed and ‘needed extra
support.’ For two carers, they described being referred to the Admiral Nurse
Service at ‘crisis point.’
Mrs Harris described how her step father is experiencing dementia but her mother
is also physically very unwell. Mrs Harris reports how relationships with her siblings
are difficult because each sibling has different opinions on how best to support their
mother and step-father. Mrs Harris described feeling ‘pulled apart’ and said that
‘juggling appointments is, in itself murder….they [Admiral Nurse] come to my house;
it’s a real blessing knowing that I don’t have to go anywhere.
Mr Jones described being referred by the Community Mental Health Team after
his wife made repeated suicide attempts, which he said that he was not coping
with. This differs from the responses that were given by the self-defined, early
stages group, who could recall how and why they were referred, with all referrals
being made by professionals and the majority of these made by GPs ‘just to give
a bit of extra support.’
4.2.1.3 Improved mental health and empowerment
For those carers in the advanced group, greatest importance seemed to be placed
on the counselling role that the Admiral Nurses undertake, closely followed by their
wealth of knowledge and experience. The combination of these two key elements
seemed to have profound effects on the carers, creating a sense of empowerment
and increasing their ability to carry on caring. This finding echoes the results of the
cost benefit analysis, which highlights a decrease in services accessed by dementia
patients and their carers.
All of the carers in the advanced category talked about valuing their time with their
Admiral Nurse:
Mr Duffy reported - ‘I save up all my worries and dump them on [Admiral Nurse]
when she comes. She has an impossible job really.’
Mrs Crowe stated that her Admiral Nurse - ‘made life easier. I rely on her quite
a bit. I confide in her: personal things. She gives sound advice. She’s saved my
mental health.
Mrs Livings spoke about the practical help that she receives from her Admiral
Nurse, saying that - ‘Before [Admiral Nurse], it felt like it was us against the world,
as well as the Government. I am always put on hold or transferred to different
departments on the phone. When I phone [Admiral Nurse] she answers straight
away. I wonder if she has a special professional’s phone number… I’d tried to get
attendance allowance and failed, but she [Admiral Nurse] helped me with the
form and got us carer’s allowance too. I didn’t even know that existed.’
Mrs Livings also talked about the role of the Admiral Nurse in arranging
respite - ‘she [Admiral Nurse] liaises with the home and sorts everything out
so I don’t have to.
Mr Jones, when talking about his wife being detained under the Mental Health
Act 1988, said ‘They [psychiatrists] were talking about sectioning her. I didn’t know
what that was. Come to think of it, I didn’t know most of what they were saying.
Thankfully [Admiral Nurse Lead] explained it. I don’t know what I’d have done
without her.
All the carers were asked what they thought would have happened if they
were not supported by the Admiral Nurses, as expected the answers were more
emotive for those carers in the advanced group. The initial response to this question
was ‘Oh good God. I can’t think about that!’ People felt that they ‘would not be able
to cope’ and that ‘things would be done a lot slower and probably the wrong way
without her.
Mr Oakley said ‘You don’t know how deep the despair goes when caring for
someone with dementia. I would not have known what to do. I would have gone
to the GP more, with despair and been bloody miserable.
4.2.1.4 Carer’s description of Admiral Nurses
The qualities that were ascribed to the Admiral Nurses by the carers they worked
with were plentiful and all positive. Words like “wonderful” and “amazing” were
used repeatedly throughout ninety eight percent of the interviews and a bar chart
of the attributes that carers assigned to their Admiral Nurses can be seen below:
2524
Carers were not only asked to tell their stories as part of this evaluation, they were
also asked to complete five point Likert scales for the following questions:
1. What has been your overall experience of the Admiral Nurse Service?
2. Do you feel that the Admiral Nurse Service has been useful to you and the per-
son you care for?
3. What impact (if any) do you feel that the Admiral Nurse Service has had for
you?
The results of these questions can be seen on the charts below:
4.2.1.5 Negative feedback analysis
Generally the feedback was extremely positive with carers giving ratings of 5 or
greater in eighty six percent of cases when describing their overall experience.
However, Mrs Henderson described a different experience of the Admiral Nurse
Service, which she attributed to her expectations. She reported that she ‘was very
grateful that someone came to see me but I was disappointed. I expected more.
Having said that, I’m not sure what I did expect.
Mrs Henderson described the Admiral Nurse that she saw as ‘helpful and
understanding and she did her best, but what was she; a support worker,
or a nurse? Maybe it would have been better if she’d seen a nurse who
specialises in dementia.’
Mrs Henderson went on to say that she ‘was given some leaflets and a
phone number but the lady [Admiral Nurse], just said how nice her home
was.’ Mrs Henderson had also been seen by a Dementia Advisor and it
appeared unclear whether she was indeed referring to the Admiral Nurse.
This highlights the need for a more cohesive approach to supporting people with
dementia and their carers to avoid confusion and ensure that they are accessing
the correct support at the right time.
Mrs Henderson also said that she had turned down support from a charity, saying
that; ‘She and her husband weren’t ready for that yet.’ She did seem to have some
regard for the Admiral Nurse Service as she said that she ‘would contact them
when things became harder’ and that she hoped ‘my negativity doesn’t mean that
the service won’t exist anymore. I wouldn’t want that to happen.
4.2.2 Q2: Has the presence of Admiral Nurses impacted on diagnosis
rates of dementia?
It was identified that from the 112 cases there were 12 cases supported to seek a
diagnosis:
6 were as a result of carers seeking support due to the issues they were
experiencing in caring for a person with a suspected dementia.
6 cases were identied as the carer having a dementia which had
been undiagnosed.
4.2.2.1 It is also highly likely that the professional liaison role has also led to
identifying an increased number of patients that would have otherwise not
received a timely diagnosis.
4.2.2.2 Anecdotally it can be stated that many cases have been identified through
discussion at GP meetings and through consultation with social workers and
primary care workers which have led to referrals being made to mental health
services for assessment.
2726
4.2.2.3 There has been a significant increase in referrals to secondary mental health
services from the surgeries covered but due to many variables not all of these can
be attributed to the presence of Admiral Nurses and this area could be explored
further in the future
4.2.3 Q3: Has the presence of Admiral Nurses had a positive impact on other
professional’s caseloads, and improved their ability to manage the
care of people with dementia and their carers more effectively?
30% of carers asked, reported that they would not have known how to access
support and in order to seek help, they would have made more routine GP
appointments for minor ailments.
4.2.3.1 Peer review findings
88% of professionals who returned the peer review questionnaires stated that they
had used the service.
• 100% stated that the service was easy to access.
94% of professionals said that the contact that they had with Admiral Nurse
Service, had improved the confidence in dealing with dementia patients and
their carers.
• 92% of professionals reported that they were not aware of a similar provision.
The 8% who disagreed with this statement reported that they felt that other
similar provisions were not to the same professional standard with regards to
level of knowledge, expertise and professionalism.
4.2.3.2 Reduced contact time
46% respondents stated that the Admiral Nurse Service has reduced contact to
their service.
• 34% respondents stated that it had made no difference
• 19% respondents stated that this question was not applicable to their job role.
Where professionals did consider that a reduction in the service had occurred, data
can be analysed further to demonstrate that:
• 60% reduction in contact time with GPs/ Psychiatrists.
• 100% of social workers reported a reduction in contact time
• 16% of nurses reported a reduction in contact time
Dr Neil Ashford Consultant Old Age Psychiatrist, who has given permission for his
name and his comments to be used as part of this evaluation, states that:
‘Part of my patch is covered by the Admiral Nurse Service and part is not. I very
much miss the availability of the Admiral Nurse Service in that part of my patch
that is not covered by the pilot.’
The Manager of the Dementia Intensive Support Team has noted a positive impact
on their caseload with fewer community referrals in the Pilot area since the Service
commenced. This may well be attributable to the work of the Admiral Nurse
Service.
Comments written by professionals were all extremely positive, for example:
‘The Admiral Nurse Service is the most valuable, helpful and reliable service that
I and the carers I see have been able to access.
Dr Ashford commented:
‘One of my roles has been to provide ANs with senior clinical expert advice.
As such, I have made few referrals to the AN service, however, it has been clear
with my discussions with ANs that they have managed a large number of cases
that would undoubtedly led to referral to specialist mental health services were
it not for their input and intervention.
Dr Ashford added:
‘The Admiral Nurse Service has provided rapid and easy access to specialist,
highly skilled support for carers of people with dementia.’ He goes on to say, ‘It
is absolutely clear that the Admiral Nurse Service should be routinely available
as a standard provision to all carers of people with dementia.
4.2.4 Q4: Have the interventions offered by Admiral Nurses reduced
admissions to Acute/Mental Health hospital beds?
4.2.4.1 In many cases there was no other alternative to admission other than
Admiral Nurse support. It was identified, using previous risk indicators and client
history that 8 admissions to Mental Health inpatient beds have been potentially
negated as a result of Admiral Nurse input. Six of these were directly attributable to
the support and expertise offered by the Admiral Nurse service, supporting the carer
to cope with the PWD increased needs and identifying and minimising potential risk
factors that may lead to a mental health crisis.
2928
These interventions therefore, prevented deterioration of the situation and negated
the need for a potential admission. Two admissions were negated by engaging
the support of the Dementia Intensive Support Team before the situation became
untenable.
4.2.4.2 The indirect admission avoidance work that has been carried out as a result
of the liaison/advisory role that the Admiral Nurses also perform has not been
quantified in this evaluation.
4.2.5 Q5: Have the interventions offered by Admiral Nurses reduced/delayed
admissions to Residential and Nursing care for people with dementia?
The Admiral Nurse Lead provided statistics gathered from ongoing service delivery
demonstrating that interventions from the team has reduced and delayed
admissions. This includes supporting carers to care at home for longer through
psychological strategies, practical strategies and supporting end of life at home.
4.2.5.1 Nine cases that required admission to care or nursing placements were
planned and therefore enabled to access support in their preferred place of care in a
timely manner, not as an immediate or crisis admission.
4.2.5.2 Research demonstrates that there is an increased likelihood of admission
to full time care for people with dementia following an acute hospital admission;
therefore by preventing the admission there is the potential to delay the need for
full time care.
4.2.6 Q6: Have the interventions offered by Admiral Nurses improved
outcomes at End of Life for people with dementia and their carers?
Three people with dementia were supported to receive End of Life care at home.
In those instances where the carer’s loved one has passed away, the Admiral Nurse
can still offer support to the carer. This has been described as ‘a lifesaver… I can’t
praise her [Admiral Nurse] enough. I can’t discuss grieving with my family and she
[Admiral Nurse] provides space and time just for me and my thoughts.
Mrs Thomas gave an amazing and emotional account of her husband’s death,
which deserves to be told in its entirety:
‘If it wasn’t for the Admiral Nurses, Steve would not have had the perfect death.
They knew what to do for him, me and the whole family. We wanted Steve
to die at home, not in a hospital where he didn’t belong. She [Admiral Nurse]
helped get him home from hospital and talked me through it. The death that is,
she told me what it was going to be like and I didn’t feel as scared. She showed
me how to look after him. All the other nurses would come in do what they
had to do and go. She [Admiral Nurse] had time for me and talked to me in a
nice way. She treated Steve as if he was part of her family.
‘When it happened we were all there, all the family sitting round his bed. She
[Admiral Nurse] left about half an hour before he passed. My daughter was
playing cards and Steve had sleep apnoea, so we had to keep waking him up.
My son said, “Mum, dad’s stopped breathing again” and I called his name a few
times and touched his shoulder. I was holding his hand with my other hand
and I said, “That’s it, he’s passed.” My daughter said “what’s it?” I replied “he’s
drifted away.” It was exactly as we’d planned it. I wouldn’t have coped so well
afterwards if it hadn’t been such a perfect death’
4.2.7 Q7: Do Admiral Nurses offer value for money in achieving Health and
Social Care targets and legislative requirements?
As part of this evaluation, a cost/benefit analysis has been completed of
particular factors during the Pilot. Further details of this can be found in Section
5 of the report.
Question seven of the peer review survey also focused on the future development
of the service, asking professionals:
• would they use the Admiral Nurse Service again;
• should it be made a permanent service; and
should the Admiral Nurse Service form part of a standard service for families
where one member is experiencing dementia.
The results of this question are conclusive, demonstrating that professionals
consider the Admiral Nurse Service as valuable as carers expressed that they do.
This can be seen in the table below:
If you have used the
AN service do you think
you would use it again
in the future?
As the AN service
is being piloted in
Norfolk, is there merit
in the service being
made permanent?
Do you feel the
AN service should
form part of standard
provision for the future
in terms of supporting
carers of those
with dementia?
92%
(8% replied not
applicable)
96%
(4% replied not
applicable)
100%
3130
COST/BENEFIT ANALYSIS 5
5.1 Overview
The Cost/Benefit Analysis was carried out in order to determine if the Admiral Nurse
Service had a positive financial impact for the health and social care economy.
This was based on the clinical information of one hundred and twelve service users
(approx. 50%) of the total cases and considered the following factors:
A. Delay/avoidance of admission to a care home;
B. Delay/avoidance of admission to a nursing home;
C. Delay/avoidance of admission to a general medical ward;
D. Delay/avoidance of admission to an acute mental health ward;
E. Increase in well-being for the person with dementia.
F. Increase in diagnosis of dementia;
G. Delay/avoidance of a referral to Improving Access to Psychological Therapies
(IAPT) /Counselling for the carer;
The Cost/Benefit Analysis has been calculated based on the numerical evidence
collected by the Admiral Nurse team. It does not consider any indirect savings that
were highlighted by carers in the qualitative strand of this evaluation
The anonymised information was shared with South Norfolk Clinical Commissioning
Group to enable tariffs and therefore costs to be attached to the outcomes that
were identified.
5.2 A-C. Delay/avoidance of admission to a care home, nursing
home and general medical ward
This section captures financial information for categories A-C where intervention(s)
by the Admiral Nurse Team prevented or delayed admission to a care home, nursing
home or acute hospital.
5.2.1 Excluded data
The data in the following table does not include the indirect admission avoidance
work that has been carried out as a result of the liaison/advisory role that the
Admiral Nurses also perform.
The costs do not reflect further savings that may have been incurred if the person
with dementia was admitted to hospital.
Many of these savings are ongoing as the people with dementia continue to be
cared for in their own home with the support of family carers and community
based services and have not been included.
5.2.2 Savings - Delayed Admission/Admission Avoidance
The following table demonstrates the direct savings of £426,601 that were identified
as a result of admission avoidance/delayed admissions to residential /nursing care
homes and acute hospital admissions between June 2013 and April 2014.
Admission Avoidance – Acute
Total savings of £63,074 due to early identification of chest infections, urinary
infections, management of non-specific conditions, falls and end of life without the
need for admission to hospital.
Delayed/Avoided Admission – Care Home
Total savings of £303,207 due to delayed admission and admission avoidance.
Delayed/Avoided Admission – Nursing Home
Total savings of £39,560 due to delayed admission to nursing home.
Continuing Health Care
Total savings of £20,760 where alternative support was implemented to meet the
needs of the patient and carer.
Savings between June 2013 - April 2014
Category of Prevented/Delayed Admission Gross Saving
Admission Avoidance
3x End of Life (EOL) £9,948
Urinary Tract Infection (UTI) £3,066
2x General Acute £4,822
10x Collapse £11,550
Falls £2,518
2x General Acute £4,822
2x UTI £5,750
2x Delirium £6,132
2x General Acute £4,822
2x General Acute £4,822
2x General Acute £4,822
TOTAL £63,074
Table continues over page
3332
Delayed Admission – Care Home
Care Home (1 week) £633
Care Home (2 weeks) £1,266
Care Home (2 weeks) £1,266
Care Home (8 weeks +) £5,064
Care Home (8 weeks +) acute admission x 2
UTI – calculated in Admission Avoidance Section £5,064
Care Home (9 weeks) £5,697
Care Home (13 weeks +) £8,229
Care Home (13 weeks) £8,229
Care Home (13 weeks) + acute admission x 2 – as above £8,229
Care Home (14 weeks +) £8,862
Care Home (18 weeks +) £11,394
Care Home (16 weeks +) £10,128
Care Home (18 weeks +) £11,394
Care Home (18 weeks +) + acute admission x 2
Delirium as above £11,394
Care Home (19 weeks) £12,027
Care Home (19 weeks +) £12,027
Care Home (22 weeks +) £13,926
Care Home (24 weeks +) £15,192
Care Home (26 weeks) + acute admission x 2 – as above £16,458
Care Home (25 weeks +) £15,825
Care Home (28 weeks +) £17,7 24
Care Home (28 weeks +) £17,7 24
Care Home (32 weeks +) £20,256
Care Home (33 weeks) £20,889
Care Home (33 weeks +) £20,889
Care Home (37 weeks +) + acute admission x 2 as above £23,421
TOTAL £303,207
Delayed Admission – Nursing Home
Nursing Home (13 weeks) EOL – as above £11,180
Nursing Home (16 weeks) EOL – as above £13,760
Nursing Home (17 weeks) £14,620
TOTAL £39,560
Continuing Health Care
1 to 1 Care Halted @ £2,590 per week reduced to
£860 for 12 weeks
£20,760
TOTAL £20,760
Grand Total £426,601
Qualifying Statement:
‘I can confirm that I have calculated the average costs using the actual prices
paid within South Norfolk for the year 13/14, These average costs may not apply
in all circumstances but have been applied using our best understanding of
the information available, quantifying a saving for the Admiral Nurse Pilot. The
quantified saving does not take into account other costs associated with change
in service and does not reflect the net gain to the CCG, but expresses the gross
savings on avoided admissions’
Sebastian Foster, Business Intelligence Analyst for South Norfolk CCG
5.3 D. Delay/avoidance to an acute mental health ward
It was identified, using previous risk indicators and client history that 8
admissions to Mental Health inpatient beds have been potentially negated
as a result of Admiral Nurse input.
Six of these were directly attributable to the support and expertise offered by the
Admiral Nurse Service, supporting the carer to cope with the PWD increased needs
and identifying and minimising potential risk factors that may lead to a mental
health crisis. These interventions therefore, prevented deterioration of the situation
and negated the need for a potential admission.
Two admissions were negated by engaging the support of the Dementia Intensive
Support Team before the situation became untenable.
Tariff costs are not currently available to provide details of monetary savings.
5.4 E. Increase in Well-being Person with Dementia
Within at least 45 of the 112 cases there was increased well-being for the person
with dementia. It is arguable that management of these areas of patient care are
likely to reduce the need for premature admission to care and minimise the risk of
crisis and its associated costs.
Influencing factors were:
Achieving diagnosis and then treatment when appropriate
Better relationships with their families /carers
Access to treatment for co-morbidities
Access to social support
Ability to remain at home for longer
Preferred place of care at End of Life
5.5 F. Increased Diagnosis Rates
As described in point 4.2.2 there were 12 cases supported to seek a diagnosis.
Of these, 50% were as a result of carers seeking support due to the issues they
were experiencing in caring for a person with a suspected dementia and 50% were
identified as the carer having a dementia which had been undiagnosed.
3534
Dr Ashford commented:
‘On occasions they (ANs) have identified people in need of specialist mental
health services, people who might otherwise have gone undiagnosed or
untreated.
This spin-off impact of the AN Service makes an important contribution to
National and Local targets to increase diagnosis rates.’
It is also highly likely that the professional liaison role has also led to the
identification of an increased number of patients who would otherwise have not
received a timely diagnosis.
The Admiral Nurse Service is assisting in achieving national targets.
5.6 G. Avoidance of referral to Improving Access to Psychological
Therapies (IAPT)/Counselling.
Twelve (12) cases were identified that would have resulted in carers being referred
to IAPT or Counselling without the intervention of an Admiral Nurse.
Due to the nature of how this service is commissioned, using a block contract, it is
difficult to offer exact cost savings. However, a report by NIHR CLAHRC (2011) states
that:
‘The average estimated cost for a course of exclusively low intensity
treatment was £493 and fluctuated between £313 (Suffolk PCT) and £901
(North & East Hertfordshire PCT). The estimated cost of a single course of high
intensity treatment was £1,416 and ranged from £987 (Suffolk PCT) to £1,793
(West Hertfordshire PCT).
It could be assumed that based on these figures, average savings of between
£5,916 and £16,992 would have been achieved.
5.7 Additional benefits and potential savings of the
Admiral Nurse Service.
Eight cases were identied as being likely to escalate to Safeguarding without
intervention from Admiral Nurse Service. Savings would be achieved in both Health
and Social Care resources, depending on the source of the referral.
• Three people with dementia were supported to receive End of Life care at home.
Nine cases that required admission to care or nursing placements were planned
and therefore enabled to access support in their preferred place of care.
Due to the presence of Admiral Nurses in Norfolk calls to the national Admiral
Nurse DIRECT phone line have increased since implementation of the pilot project.
For the Norfolk area, in the three year period 2010 - 2013 there were 28 contacts,
on average 9.3 contacts per year. In the 10 month period June 2013 to end April
2014 there were 57 contacts (27 of those coming in January - April 2014 alone.)
demonstrating a 760% increase in contacts this year. This demonstrates that
awareness of the Service has increased and the National Phone Line is enabling
those outside the pilot area to access specialist help and advice.
All appropriate cases were introduced to the concept of Advanced Care
Planning (ACP). This reduces the likelihood of unplanned admissions to acute
and nursing care.
Seventy ve percent (75%) of carers made reference to experiencing low
mood, depression and anxiety symptoms, as well as an inability to cope with
their situation prior to input from the Admiral Nurses. This potentially could have
led to these individuals accessing secondary care mental health services.
Co-facilitation of End Of Life and Dementia Training with Norfolk Community
Health and Care (NCH&C ) palliative care staff. Cost neutral, additional expertise
is offered.
Specialist signposting for health, social care and voluntary sector employees
on all aspects of dementia care and supporting carers.
Participation in operational and strategic boards to improve outcomes
for people with dementia and their carers.
Integrated working across health, social care and voluntary services to
improve outcomes for Organisations, PWD and carers.
A potential reduction in medication costs as a result of the Admiral Nurse
involvement both for the carer and the person with dementia as a result of
therapeutic interventions as opposed to medical intervention. This area
would require more research to validate the statement.
3736
CONCLUSION 6
6.1
The evaluation has proved that the Admiral Nurse Service has had a positive impact
on the seven key areas that were investigated (section 1.2).
It has demonstrated that the success of the Admiral Nurse Service is multifaceted:
• professionals rate the service as “excellent and vital” (GP),
• it provides much needed appropriate support and is a “life line” to carers,
• it has the potential to create savings for both Health and Social Care.
6.2
The Admiral Nurse Service is highly valued, but it is not currently
commissioned, and this was highlighted by a GP who said that:
‘It is sometimes difficult to remember that the Admiral Nurse Service
should be an additional service not the only service provision.’
6.3
Carers mirrored the above, by stating that it would have been better if they could
have accessed support prior to reaching crisis point. Therefore it would be hoped
that if this service is to be commissioned in the future these carers would be able to
access support earlier and minimise the risk of a crisis occurring. It was noted that
as this is a pilot service provision many of the carers had been caring
for some time before they received support.
During the process of this evaluation, many individuals have commented on
their experiences of the Admiral Nurse Service, which has been evaluated to be an
exceptional service, where professional, expert knowledge, delivered in a sensitive,
empathic manner has enabled carers to continue caring through the ‘despair’ and
‘traumatic experiencing of caring’ to help them ‘rebuild emotional reserves’ and
allow for ‘a perfect death’.
Those carers who considered that their relative was not suffering from an advanced
dementia, talked about using the Admiral Nurses as a “safety net.” How, and if the
Admiral Nurse Service is developed, was not the remit for this evaluation however
this raised the question of whether it is necessary that this safety net is managed
by a Band Six Practitioner. If an unqualified practitioner/support worker was used for
this role, then there could be an increase in the volume of carers who needed more
intensive level of support, being seen by the qualified members of staff.
6.4
The Admiral Nurse Service does not, however, just benefit service users and
front-line professionals, it is also a cost effective service.
It has been clearly identified by professionals that there is a benefit to them
both in terms of increased confidence and competence, and by reducing their
workloads. At a time when both GP’s and Social Work colleagues are struggling
to cope with the increased demands upon them it could be argued that a robust
Admiral Nurse Service could reduce caseloads further and enable professionals
to work more efficiently when they are managing the care of people with
dementia and their carers.
Evidence also suggests that if an Admiral Nurse Service is commissioned that this
would increase confidence to diagnose those with a suspected dementia. A survey
carried out by the Norfolk and Suffolk Dementia Alliance in 2013 found that one
of the key concerns when considering diagnosis was the lack of easily accessible
relevant post-diagnostic support for people with dementia and their carers. The
evaluation has confirmed that this service is considered accessible and that there
is no equivalent service available. The need to increase diagnosis rates as set out
by NHS England, will be more achievable with this service in place.
The Admiral Nurse Service Pilot has evidenced savings to the health and social
care economy of £426,601 and has effectively demonstrated that gold standard
clinical care does not have to create a financial deficit. It must also be recognised
that sizeable savings to the system are not attributed in monetary terms.
Total costs to set against savings cannot be fully quantified at the time of this
report. Current funding information for Year One is as follows: The Peoples Health
Lottery via Dementia UK supplied £60,000 of funding to Age UK Norfolk and NSFT
allocated funding for 1.65 WTE Band 6 nurses from current budgets.
6.5
The current service provision is in its infancy and has already demonstrated that
significant savings and benefits can be achieved by supporting families/carers
of dementia. By implementing the Service to meet policies, (both national and
local) alongside assessing the need locally there are key elements that have been
identified that should inform future service development.
A revised dementia pathway, and Admiral Nurse resources within this, will require
further investigation. One Band Seven and two Band Six nurses (1.65WTE) have
achieved outstanding results throughout the Pilot, and if the service is to continue
providing excellent care, resourcing needs of the service need to be determined.
3938
APPENDIX 7
Methodology and procedure
A mixed methods approach allows the researchers to build knowledge on
pragmatic grounds (Creswell, 2003; Maxcy, 2003) asserting truth is ‘what works’
(Howe, 1988). A mixed methods evaluation requires the consideration of three
issues: priority, implementation, and integration (Creswell, Plano Clark, Guttman,
& Hanson, 2003). Priority refers to which method, either quantitative or qualitative,
is given more emphasis in the study. Implementation refers to whether the
quantitative and qualitative data collection and analysis comes in sequence
or in chronological stages, one following another, or in parallel or concurrently.
Integration refers to the phase in the research process where the mixing or
connecting of quantitative and qualitative data occurs.
This evaluation utilised a convergent design, where both qualitative and
quantitative strands are conducted separately yet concurrently and merged
at the point of interpretation. Equal priority is given to each strand and it ensures
a more complete understanding of the impact that the Admiral Nurse Service has
had on the families that access support and on the wider medical community.
Data Collection - Qualitative Strand
The qualitative strand of the evaluation focuses on identifying the value that
carers place on the service that they receive from the Admiral Nurses. This was
achieved using a cross-sectional survey design, where the data collected at one
point in time (McMillan, 2000), was used. The primary technique for collecting the
quantitative data was a self-developed questionnaire for use in a semi-structured
telephone interview, containing items of different formats: self-assessment
items, measured on a 5-point Likert scale, and open-ended questions. A panel
of professionals representing different organisations (e.g.: Norfolk and Suffolk
Foundation Trust. Age UK) was used to secure the content validity of the survey
instrument. The questionnaire consists of nine questions plus Likert scales that
asked the participant to consider the level of impact and the nature of the service
provided by the Admiral Nurse team. The survey also aimed to establish how the
coping mechanisms employed by the carer would differ if they had not received
a service from the Admiral Nurse team.
Carers Interview Script
(Information for the interviewer please read before making the call):
Remember not to reword the questions so that they are leading to the interviewee.
We need to make sure we obtain as honest opinions as possible.
Before you start interviewing please explain that we are asking questions as part of a
Service Evaluation of the Admiral Nurse Service. Remind the interviewee that we will
be recording what they say and that information given may be used (as anonymous
quotes) as part of our final evaluation. If they would like something
not recorded they are able to request that a record is not made of that part of
the conversation.
Participant ID ________________________ Date _______________ Time ___________
1) Please tell us how you/why you made contact with the Admiral Nurse Service
2) What has been your overall experience of the Admiral Nurse Service?
3) Do you feel that the Admiral Nurse Service has been useful to you and the
person you care for – can you tell us why?
4) What impact (if any) do you feel the Admiral Nurse Service has had for you?
5) Have you had access or made any other contact to other services to support
you? If so can you tell us which services and what impact they had for you?
6) Did the Admiral Nurses identify any further services for you to access?
7) Can you tell us how (if at all) the Admiral Nurse was different from other help
and support you have received?
8) Do you have any further comments about the Admiral Nurse Service?
Quantitative Strand
The quantitative strand of the evaluation focuses on identifying the usefulness
of the Admiral Nurse Service as deemed by professionals. A cross-sectional survey
design was again used and consisted of an anonymous questionnaire that used
both: dichotomous and open ended questions. There were sixteen questions in
total, which were separated into five categories, asking for professional opinions on
accessibility of the service, providing information, the patients’ views on the service,
the impact of Admiral Nurses and whether or not the professional would use the
service again.
Paper Feedback Form
The paper feedback form can be found over the following three pages.
4140
4342
Data Analysis
The return rate on the peer questionnaires was too low to allow for statistical
analysis: twenty eight of one hundred questionnaires were returned and two of
these had to be discarded because of insufficient data. If a statistical analysis of the
data had been carried out, type 1 or type 11 errors would have occurred. Had the
return rate been better, a X2 analysis would have been used to demonstrate trend,
or a Mann-Whittney U test (with correction for ties) would have been an appropriate
analysis to use. It is the intention of the researcher to re-administer the peer review
questionnaires and analyse the data at a later date.
The returned questionnaires were still useful and allowed for a simple break down
of the data to create percentage values whilst considering the impact of the
Admiral Nurse Service on professionals and the views on whether or not the service
should continue.
Validity
In quantitative research, reliability and validity of the instrument are very important
for decreasing errors that might arise from measurement problems in the research
study. Validity refers to the degree to which a study accurately reflects or assesses
the specific concept or construct that the researcher is attempting to measure
(Thorndike, 1997). Content, criterion-related, and construct validity of the survey
instrument were established. Content validity shows the extent to which the survey
items and the scores from these questions are representative of all the possible
questions. The questionnaires have been examined by a panel of professionals
involved with the commissioning of Admirals Nurses.
Criterion-related validity, also referred to as instrumental or predictive validity, is
used to demonstrate the accuracy of a measure or procedure by comparing it
with another measure or procedure, which has been demonstrated to be valid
(Overview: Reliability and Validity, 2001). For this purpose, the qualitative data
derived from the carer and professional questionnaires will be compared.
Construct validity seeks agreement between a theoretical concept and a specific
measuring device or procedure. To achieve construct validity, factor analysis of the
Likert type survey items was performed. Factor loadings for survey items will show
a correlation between the item and the overall factor (Tabachnick & Fidell, 2000).
Ideally, the analysis should produce a simple structure, which is characterized by
the following: (1) each factor should have several variables with strong loadings,
(2) each variable should have a strong loading for only one factor, and (3) each
variable should have a large communality, i.e. e. degree of shared variance
(Kim & Mueller, 1978).
4544
Qualitative Data Collection
The multiple case studies design (Stake, 1995) was used for collecting and analysing
the qualitative data. A case study is a type of ethnographic design (Creswell, 2002;
LeCompte & Schensul, 1999) and is an exploration of a “bounded system” or a case
over time, through detailed, in-depth data collection involving multiple sources of
information and rich in context (Merriam, 1988; Creswell & Maitta, 2002). In this
investigation, the instrumental multiple cases (Stake, 1995) will serve the purpose of
“illuminating a particular issue” (Creswell, 2002, p. 485), such as how Admiral Nurses
supported the carers when their loved one was dying.
The primary technique will be conducting in-depth semi-structured telephone
interviews with the carers of someone from dementia. Triangulation of different
data sources is important in case study analysis (Creswell, 1998). The Likert scales
and data from the peer reviews will be used to validate the case studies.
Data Analysis
In the qualitative analysis, data collection and analysis proceed simultaneously
(Merriam, 1998). In the qualitative phase of the evaluation, the verbal data obtained
through semi structured interviews was coded and analysed for themes.
The steps in qualitative analysis included: (1) preliminary exploration of the data
by reading through the transcripts and writing memos; (2) coding the data
by segmenting and labelling the text; (3) using codes to develop themes by
aggregating similar codes together; (4) connecting and interrelating themes; and (5)
constructing a narrative (Creswell, 2002).
Establishing Credibility
The criteria for judging a qualitative study differ from quantitative research.
In qualitative design, the researcher seeks believability, based on coherence,
insight, and instrumental utility (Eisner, 1991) and trustworthiness (Lincoln &
Guba, 1985) through a process of verification rather than through traditional
validity and reliability measures. The uniqueness of the qualitative study within
a specific context precludes it’s being exactly replicated in another context.
However, statements about the researcher’s positions – the central assumptions,
the selection of informants, the biases and values of the researcher – enhance
the study’s chances of being replicated in another setting (Creswell, 2003).
To validate the findings, i. e., determine the credibility of the information and
whether it matches reality (Merriam, 1988), three primary forms will be used
when considering the data obtained from the semi structured interviews: (1)
member checking – getting the feedback from the participants on the accuracy
of the identified categories and themes; (2) providing rich, thick description to
convey the findings; and (3) external audit – asking a person outside the project
to conduct a thorough review of the study and report back (Creswell, 2003;
Creswell & Miller, 2002).
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Age UK Nor folk is the operat ing name of Age Concer n Norfolk, a Char itable Company limi ted by guarantee Regi stered in England nu mber 03783205. Registere d charity numbe r 1077097.
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... A case management approach also harnesses expertise from all areas to ensure care is delivered in a consistent, efficient and cost-effective way (MacNeil et al, 2015;Harrison Dening et al, 2017), which meets the aims of the EHCH framework. There are several benefits that Admiral nursing can bring to EHCH: increasing the recognition and diagnosis of dementia (Aldridge and Findlay, 2015); preventing avoidable hospital admissions through better management of comorbid conditions (Knight and Harrison Dening, 2017); improved decision-making and advance care planning ; and increasing the confidence and capacity to care for people with dementia across the workforce . ...
... Care home residents are also less likely to have access to the usual primary care services and resources available to people living in the community (Lee et al, 2019). Admiral nurse case managers can support care home staff and the primary and community care team to manage and monitor comorbid conditions or intercurrent acute conditions superimposed on dementia to reduce any avoidable hospital admissions (Aldridge and Findlay, 2015;Knight and Harrison Dening, 2017). This may involve several interventions-for example, educating care home staff and the wider primary care team to understand the interplay of dementia with other physical conditions and in differentiating between conditions, such as dementia, delirium and depression. ...
Article
Background The UK older population is higher than the global average. Over the next 20years, England will see an increase in the number of older people who have higher levels of dependency, dementia and comorbidity, many of whom will require 24-hour residential care. It is estimated that 70% of residents in nursing and residential care homes either have dementia on admission or develop it while residing in the care home, many of who will have complex needs with high levels of multimorbidity. However, there is a lack of consistency in the provision of primary care and specialist services to this population and a known gap in knowledge and skills of dementia care in care home staff and primary care teams. Methods This article considers the current health policy drivers to enhance integrated health and social care provision to care homes and proposes a model of care that would support the aims of the NHS Long Term Plan for care to be delivered closer to home and improve out of hospital care which includes people who live in care homes by introducing Enhanced Health in Care Homes. It is crucial that such a model includes the correct skill mix to meet the needs of the care home population. Conclusions There are currently gaps in service provision to many care homes. Admiral nurse case managers and specialists in dementia care, are well placed to support the delivery of Enhanced Health in Care Homes and improve access to specialist support to care home residents, their families, care home staff and the wider health and social care system.
... The service was evaluated using a mixed methods design to collate data which included questionnaires for professionals, interviews with family carers and case reviews with several positive outcomes being identified [49];  Improved physical, emotional and mental wellbeing for people with dementia and their families; ...
... • Improved communication between services. As a result, there were positive benefits for health and social care services with potential savings in excess of £426,000 over a 10-month period (Aldridge & Findlay, 2014). These outcomes also reflected some of the key objectives of current policy being developed in the UK. ...
Article
Services for people with dementia and their families in England are commissioned with a lack of integration and an inconsistent approach creating gaps in service provision. Therefore, families affected by dementia are not receiving the appropriate care in a timely manner and often access support at crisis point. This reactive and crisis driven approach to care is costly financially and can have a negative impact and quality of life of those affected. The ABC model offers an adaptable framework that can inform service provision and improve opportunities to create seamless peri- and post-diagnosis dementia services for families affected by dementia.
Article
Full-text available
Introduction: The rising prevalence of dementia has led to increased numbers of people with dementia being admitted to acute hospitals. This demand is set to continue due to an increasingly older population who are likely to have higher levels of dependency, dementia, and comorbidity. If admitted to the hospital, people with dementia are at higher risk of poor outcomes during and following a hospital admission. Yet, there remains a significant lack of specialist support within acute hospitals to support people with dementia, their families and hospital staff. Methods: Admiral Nurses are specialists that work with families affected by dementia and provide consultancy and support to health and social care colleagues to improve the delivery of evidenced based dementia care. Historically, Admiral Nurses have predominantly been based in community settings. In response to the increasing fragmentation of services across the dementia trajectory, the Admiral Nurse model is evolving and adapting to meet the complex needs of families impacted upon by dementia inclusive of acute hospital care. Results: The Admiral Nurse acute hospital model provides specialist interventions which improve staff confidence and competence and enables positive change by improving skills and knowledge in the provision of person-centred dementia care. The role has the capacity to address some of the barriers to delivering person centred dementia care in the acute hospital and contribute to improvements across the hospital both as a result of direct interventions or influencing the practice of others. Conclusion: Improving services for people with dementia and their families requires a whole system approach to enable care coordination and service integration, this must include acute hospital care. The increasing numbers of people with dementia in hospitals, and the detrimental effects of admission, make providing equitable, consistent, safe, quality care and support to people with dementia and their families a national priority requiring immediate investment. The inclusion of Admiral Nursing within acute hospital services supports service and quality improvement which positively impacts upon the experience and outcomes for families affected by dementia.
Book
Rev.& expanded from Case study research in education,1988.Incl.bibliographical references,index
Book
How can adults update skills, keep up with recent developments in their field, or prepare for a new career when they have full-time jobs and family obligations? Distance education has increasingly served this growing, nontraditional student population with convenient ways to learn - at home or on the job, at their own pace and on their own schedule. And in this book, authors Verduin and Clark give adult educators in a range of fields, from higher education to the military, a comprehensive reference for developing creative, nontraditional approaches to learning by using a variety of media in a wide range of settings. They present an innovative approach to distance instruction based on learning objectives and show how teachers and administrators can use this approach in planning courses, teaching, interacting with students, and assessing learning outcomes.