The Swedish pilot project:
The Skaraborg care system is situated in the north-eastern part of the Western region, located between the two largest lakes in Sweden, Vänern and Vättern. Healthcare services are provided by the Skaraborg hospital, the primary care units and the communities, serving a population of 260 000 inhabitants.
The Skaraborg Hospital (SHG) is the specialist hospital group in Skaraborg, consisting of four hospitals in the towns of Lidköping, Skövde, Mariestad, and Falköping. SHG has two emergency departments at the Skövde and Lidköping hospitals. SHG offers services including acute and planned care in 30 different medical specialities. The hospitals have 700 beds. During a year the services entail 45 000 inpatient episodes, 210 000 outpatient visits to physicians, 20 000 surgical procedures and 2 500 births. Furthermore, in Skaraborg there are 34 primary care units and 15 communities that together with SHG have the overall responsibility for dementia diagnosis and treatment. The prevalence of dementia in Sweden in people older than 65 years is 7%, which corresponds to more than 15000 inhabitants in Skaraborg with varying degrees of cognitive impairment.
Care pathways for patients with mild cognitive impairment and dementia:
All the three care providers play a role in the care pathway for these patients. The primary care centres are responsible for the initial examination of patients with suspected MCI or dementia. The basic assessment aims to involve multiple perspectives on the patients’ current condition including his or her social situation:
- A structured anamnesis including interviews with nearest and dearest
- An assessment of the physiological and psychological condition of the patient
- Cognitive tests including MMT and the Clock test
- A structured assessment of patient activities of daily life and level of activity
In addition, tests to include other conditions include:
- A CT scan
- Relevant neuropsychological tests
- Blood tests to exclude hyperkalaemia, high levels of homocystein as well as of thyroid hormones
- In case of clinical suspicion, the basal investigation also includes liquor tests for Borrelia and Syphilis
The physician and a specialized nurse at the primary care unit continuously monitor patients with MCI. The monitoring includes at least yearly visits to the physician, including a pre-visit to the specialized nurse according to the Swedish National Guidelines for dementia care. Moreover, patients can contact the specialized nurse at request at any time between visits to the physician. If patients with MCI or mild dementia deteriorate and develop moderate/severe dementia, the aid assistance coordinator, who belongs organizationally to the community, designs an individual care plan for those patients together with representatives from the hospital and the Primary Care Centre. Based on the care plan, community care resources are made available for the patient, including basic home care. Basic, long-term care of patients with dementia is provided by cross-professional teams under the management of the community. These teams are also led by a specialized community nurse with the support from the general practitioner and the specialized nurse at the primary care centre. The primary care physician has always the overall medical responsibility for the patient.
A special investigation unit at SHG, the Centre for Elderly Patients in need of Psychiatric Care, CEPP – might be also involved in the long-term care of the patient, giving advanced medical advice to the primary care unit and to the community. The CEPP is the main centre for dementia at SHG, serves the entire Skaraborg care system and supports the municipalities and the primary care units in various ways. The CEPP has an inpatient clinic that has the capacity to care for 12 patients simultaneously, as well as an outpatient clinic consisting of a senior physician, specialized nurses, psychologists, welfare officers and occupational therapists. The outpatient clinic is responsible for the care of around 450 patients at any time and there is a continuous flow of 15 referrals/week. The clinic carries out 200 investigations each year out of which 100 patients/year are diagnosed with dementia. Currently, CEPP is also the home base for the mobile team that specializes in patients with cognitive impairment. This team consists of a senior physician and a specialized nurse and serves the entire county. In addition, there are three other mobile teams in Skaraborg (that belong organizationally to SHG) that care for instable older patients with multiple diseases. These latter teams will constitute the core of the future networked mobile care model for patients with CI and dementia in Skaraborg
In addition, there are several local care centres for patients with moderate and severe dementia in the municipalities. However, patients with severe or complex symptoms and concurrent diseases are referred to SHG for further examination. The hospitals in Skövde, Falköping and Lidköping have the capacity to take care of patients with complex care needs. In particular, they provide care for multi-diseased patients with Dementia.
The Skaraborg care system and the DECI project:
The Skaraborg care system has a long tradition of research connected to the organizing of healthcare services, especially regarding care for patients with chronic diseases and elderly patients with multiple illnesses. New integrated care models for these patients have been developed in most parts of Skaraborg. The care model is involves all the care providers (the hospital, the primary care centres and the communities). So far, internal as well as external assessments have shown very good results from a patient as well as a medical perspective. Thus, the care models for patients with chronic diseases are to some extent already well developed and the DECI platform will be an excellent supplement for the further integration of networked care for patients with MCI and dementia.