Could do better, audit into ACT dementia assessment services finds

A lack of digital health record policies, performance measurement, standardisation and clear support service referral pathways are hampering service planning and delivery.

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Planning and reporting needs improvement, there are sometimes long delays in communicating with doctors, and the Canberra Health Service’s dementia services could better to support clinicians in their decision making.

Those are the findings of the ACT Audit Office which has cast its eye over the specialist assessment services for dementia and cognitive decline in the territory.

The auditor found that the CHS could not know if it was meeting community needs because it did not monitor referrals and, due to limitations in its use of the digital health record, did not know the wait times between referrals and first appointments.

The number of people living with dementia in the ACT is projected to increase by 102% by 2054, from 6100 to 12,300 people and “[t]imely access to specialist assessment services has potential benefits for those diagnosed with dementia or cognitive decline and their care partners, as timely treatment can slow functional decline, provide opportunities to plan for the future and enable access to community-based supports”, the ACT Audit Office said.

The CHS operates three services which specifically provide these services: the General Geriatric Clinic, the Memory Assessment Service; and the Rapid Assessment of the Deteriorating Aged at Risk service. They are within the Geriatric Medicine Unit, which is in the Rehabilitation, Aged and Community Services division of CHS.

The audit found problems with strategic planning, which it acknowledged was expected to improve once the first ACT-specific, evidence-based framework for care for people with behavioural and psychological symptoms of dementia was developed by the Health and Community Services Directorate.

But there was no documentation showing how the ACT would implement the National Framework for Action on Dementia 2006-2010 or the National Framework for Action on Dementia 2015-2019 priorities for action, and no ACT-specific action plan to guide dementia care in the ACT.

As things stood, it wasn’t clear which service was responsible for each of the actions and deliverables identified in the RACS annual business plans. And the GMU didn’t have a documented workplan identifying deliverables, targets or performance measures for itself and any of the three services.

A clear, documented referral acceptance eligibility criteria and a prioritisation framework for the delivery of services was absent. And there was a “limited understanding” of referral patterns and no monitoring of referral sources.

Furthermore, the limitations of the digital health record have prevented the CHS from knowing what the wait time was between referral and first appointment, the auditor found.  There was no standard operating procedure for inputting information in the DHR and there were no data collection policies.

“The GGC, MAS and RADAR service are unable to effectively monitor performance data relating to referral rates and sources, wait times or staff workload and are unable to effectively monitor and report on performance,” the report said.

“Not monitoring referral patterns to the services, or accurately knowing wait times for the services, has significant implications for service planning and service delivery and CHS’ ability to demonstrate it is meeting the community’s needs.”

The lack of information able to be accessed from the DHR affected the RACS executive committee and quality and safety committee’s ability to properly oversee performance, and compromised the ability of managers, senior clinicians and the executive to identify problems or opportunities for improvement, the report said.

In addition, “[s]ome staff in the RACS division carry out multi-faceted roles where functions alternate between the front-line clinical staff, managers, senior clinicians and executive responsibilities”.

“This means there is a risk that staff do not understand their responsibilities as they pertain to performance reporting, monitoring and management,” the auditor noted.

There was also no standard way to communicate a diagnosis of dementia or mild cognitive impairment, results and next steps, and no framework with expected timeframes for communication between the services and referring doctors.

And there was no repository of information for post-diagnosis care.

The auditor-general has made nine recommendations to improve CHS’s planning and delivery of assessment services:

• CHS should ensure that the GMU develops an annual unit work plan and identify appropriate mechanisms for monitoring and reporting on performance against established performance measures.
• CHS should develop its information management and processing capabilities to monitor and report on sources of referral to the GGC, MAS and RADAR service.
• CHS should liaise with the Capital Health Network to review and update the service-specific referral criteria that is published on the HealthPathways Portal for the GGC, MAS and RADAR service.
• CHS and the Health and Community Services Directorate should collaborate to develop source system capabilities to monitor and report on wait time data for the GGC, MAS and RADAR service.
• CHS should review and improve information provided in pre-appointment client letters for the GGC, MAS and RADAR service.
• CHS should develop and maintain a repository of information, resources and available supports that clinicians can easily access and provide to clients and care partners following a diagnosis of dementia or mild cognitive impairment where appropriate.
• CHS should develop and implement models of care for the GGC and MAS, and update the RADAR model of care as required, to reflect:
  1. referral acceptance eligibility criteria in accordance with the requirements of the CHS Medical Specialist Outpatient Referral Acceptance (Adults and Children) Policy;
  1. a framework for prioritising accepted referrals;
  1. a formal process and protocols for managing and supporting clients and care partner(s) in distress whilst waiting for an appointment;
  1. minimum standards for communicating diagnoses, test results and next steps;
  1. protocols for the provision of a post-feedback follow up session and additional follow-up sessions, where it is identified by clinicians as required;
  1. defined risk reduction information that is to be provided to clients diagnosed with early stages of dementia or Mild Cognitive Impairment; and
  1. a common approach for the delivery of risk reduction information across CHS’s specialist assessment services for dementia and cognitive decline.
• CHS should develop:
  1. a standard operating procedure(s) for the collection and storage of referral information in the DHR relating to the GGC, MAS and RADAR service; and
  1. guidelines that specify minimum requirements, including the fields that should be used, to support the consistent collection of clinical information in the DHR.
• CHS should review and update the Consumer Feedback Management Policy to:
  1. clearly define roles and responsibilities for responding to feedback; and
  1. establish a process to confirm whether business units have appropriately addressed feedback.

Read the full report here.