A total of four adoption sites joined the national Adopt and Spread Programme and due to COVID-19 (restrictions and re-deployment), the adoption process were paused for all teams. One adoption site in Swansea Bay University Health Board restarted their project and used the technology-enabled dementia triage process. Here is the experience from Katy Slicox’s perspective.
Adoption at the Cwmtawe Primary Care Occupational Therapy Service
The Cwmtawe Primary Care Occupational Therapy Service was new when the lead Occupational Therapist (OT) liaised with the Community Dementia Team, where the potential for a technology-enabled dementia triage pathway (using the CANTAB tool) was discussed. This was the stage at which the national Adopt and Spread programme were inviting applications for adoptions sites to come forward for this Bevan Exemplar site. This sparked an instant interest due to the close alignment of the new OT services aims and objectives of delivering an early, proactive, holistic service.
OTs can play a vital role in the assessment of cognition and how this may impact daily living for that individual and their care-givers. The dual trained nature of our skill-set working across physical and mental health enables us to identify areas of dysfunction, complete standardised and non-standardised assessments to help with diagnostic processes and highlight particular areas of concern and success for that individual. We work with patients and care-givers to develop meaningful goals, strategies, provision of advice, equipment and signposting to promote independence, safety and empowerment.
By having access to the CANTAB tool, and with support from the Bevan Commission, the opportunity to complete a test of concept embedding an innovative, highly sensitive and easy to administrate cognitive screening tool (CANTAB) was deemed a too good prospect to miss!!
Aim at the start of the Project
To support the efficient triaging of individuals presenting with memory problems and improve the pathway for their support and well-being
Those who experience or are worried about their memory could be seen and assessed promptly, an initial intervention plan developed and onward appropriate referrals and discussions made. Through the implementation of the triage tool, it would have the potential to reduce the number of unnecessary referrals to secondary services and utilise existing services. By using the same cognitive screening tool as the community team and being an adopter of the project, will allow consistency of assessments and good working relationships. As a result, the pathway for individuals from first point of contact to diagnosis of a cognitive impairment and supporting the individual following this would be streamlined.
The project is supportive of organisational and national policies and targets, with the project encompassing a co-productive way of working, streamlining services, increasing communication between services, promoting care closer to home and providing earlier intervention. This is in line with the objectives of NICE guidelines for the management of long term conditions, Healthier Wales, Swansea Bay health board values and Cwmtawe cluster aims.
- Embracing technology, reducing paper-based assessments.
- Non-registered professionals can complete initial assessment.
- Depending on the results of the CANTAB, an individual can be assessed for other conditions within the tool. For example, the CANTAB can highlight if someone is presenting with symptoms of a depressive disorder. This can therefore inform other possible support services or interventions.
- Help to identify clinical cases that might have otherwise been missed and may present later in a person’s health journey at point of crisis, increasing patient’s safety.
- Patients receive an appropriate, standardised and reliable assessment tool. CANTAB tool demonstrates 100% sensitivity and 92% specificity in terms of correct identification of possible Dementia (usually Alzheimer’s, but would also include ‘other’ dementias where there is an impact on cognition). This is therefore a highly valid and accurate tool that can be utilised within Primary Care.
- Reduced demand on GPs to see individuals presenting with memory impairments, increasing their capacity to see medically unwell patients.
- Receive more appropriate referrals to memory clinics, less of the possible ‘worried well’ patients who may not need a more in-depth assessment.
- Reduced unscheduled hospital admissions due to issues relating to managing cognitive impairment due to earlier identification and support services being available/increased awareness.
Shortly after starting the project, COVID-19 significantly altered service delivery. This resulted in fewer opportunities for face-to-face contacts and the use of telephone/video consultations. The CANTAB tool requires the patient to be present and supported whilst they are using the platform, so this affected the number of patients who could access the new service.
Another significant impact on implementation was the disbanding of the Community Dementia Team in Swansea Bay University Health Board. This was part of the streamlining that we wanted to achieve and removed the opportunity to work with improving the referral pathways between services for the early identification of dementia.
Both these challenges resulted in a review of the aim and following discussions, it was decided that the CANTAB tool would be used just by the OT Lead to establish appropriateness of use in the future without initial stakeholders and supportive services. CANTAB tool was used as appropriate when seeing patients in the surgery and in their own homes with a total of 21 patients by April 2021.
Benefits using CANTAB
Within the limited time spent using the tool I found there to be several benefits.
- The assessment automatically produces a print off which can be sent directly and securely to an email address detailing the results of the assessment in a clear and professional manner
- Time-effective assessment
- Less ‘clinical’, patients found it a novel experience
- Good use of technology, environmentally friendly as using less paper
The feedback from GPs and patients were positive.
“The reports are aesthetically pleasing and I can see how it would be beneficial to provide patients reassurance if everything is normal for that persons gender, age and educational background”GP
“I thought it was going to be very stressful, it was okay”
“It’s very modern”Patients
Challenges during the feasibility testing
- Following the disbanding of the Community Dementia Team, CANTAB was not being used by any primary or secondary services with SBUHB. The team that would have supported the project were no longer available, therefore there was reduced awareness of tool and scoring system, and how to use it.
- The Primary Care OT service was very much in its infancy itself, with only the lead OT developing, providing and evaluating the service. There was no funded dedicated time allocated to the adoption site lead and there were competing priorities to be able to manage the adoption and adaptation.
- As fewer patients were involved than originally intended, it has not been possible to make full use of the tool. This has meant that the service evaluation was not completed to the originally intended stage.
- As the CANTAB tool relies on a less in-depth assessment and did not have a breakdown of areas of dysfunction, the OT needed to complete further assessment and this was completed without the support of a specialist community team as originally intended.
- The functional report produced was ‘patient reported’ meaning that there was sometimes confusion with the report itself on which area could be potentially inaccurate due to errors from self-reporting.
- As the breakdown of the answers on the mood assessment was insufficient, it was difficult to work with the final reports.
Despite the demonstrated benefits of the technology-enabled dementia triage (CANTAB tool) pathway, the licensing will not be extended following this project. This is due to the limited success (as part of a small test) of the adoption project and the need for a more in-depth assessment to be put in place. The need to be aligned with the mental health services within the Health Board for the technology itself was also an important point for consideration. However, it is important to note that if the OT team expands, or MDT frailty teams were to be developed to included non-registered staff this would certainly be an area of interest for the future to increase capacity to assess more individuals.