1 developments and progress dr martin freeman gp clinical lead for dementia services
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Developments and progress
Dr Martin Freeman
GP Clinical Lead for Dementia Services
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Key issues
Raise awareness Early diagnosis Clear management of dementia as a LTC Support that is available Role of carers Personhood Information
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Awarenessand
Identification
Diagnosis Assessment Management
Planning
Management of Long term condition
Patient supportCarer support
Mapping the Pathway
End of life care
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New roles
Community Dementia Nurse (CDN)
Mental health nurse, dementia experience Provider – 2gether NHS Foundation Trust Community based/Primary Care focus Named link to practice Diagnosis Long term support Care planning and regular reviews Expert training resource for managing dementia in
primary care
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New roles
Dementia Advisor (DA)
National Dementia Strategy recommendation Jointly commissioned by PCT and GCC from third
sector through tender process Named advisor for each patient Support for the long term Signposting Accessible from diagnosis to end of life Knowledge of local resources and services Develop and facilitate peer support networks
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Awarenessand
Identification
Diagnosis Assessment Management
Planning
Management of Long term condition
Patient supportCarer support
Mapping the Pathway
End of life care
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Awareness / Early diagnosis
Approx 6% over 65 yrs Approx 30% over 90 yrs Only 30% currently identified and support formally
offered National Dementia Strategy recommends early
diagnosis Challenging stigma
Does this raise ethical issues?
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Diagnosis pathway
We need to identify the 70% of people who have not been diagnosed
A joint exercise for primary care and secondary care
New pathway in draft to support this Pathway will be discussed in the Primary
Care Dementia Service Redesign Workshop
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At time of diagnosis
Care plan Community Dementia Nurse Dementia Advisor Information / education for patient and carer –
(Managing Memory Together) Treatment plan
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Awarenessand
Identification
Diagnosis Assessment Management
Planning
Management of Long term condition
Patient supportCarer support
Mapping the Pathway
End of life care
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Monitoring / Planning care
Care plan Within 4 weeks of diagnosis
Health Action Plan Led by the Community Dementia Nurse Supported by Dementia Advisor
Annual Health Check By primary care, informing the Health Action Plan
End of Life care plan
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Medicines Management
Shared guidelines As per NICE Initiated by consultant psychiatrist Monitored 6 monthly by Community
Dementia Nurse (MMSE score) GP and Community Dementia Nurse review
with consideration of stopping
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Problem management
Mental health / behavioural problems Primary Care and Community Dementia Nurse Referral to consultant psychiatrist
Acute hospital admission – DGH/Community Supported by Dementia Liaison Nurses New pathways in hospital
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Other Long Term Conditions
All strategies inclusive of patients with dementia (e.g. falls / strokes)
Palliative care support – inclusion in EoL strategy
Consideration of timely planning
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What else is out there?
Range of services Intermediate care Housing support Telecare Short breaks Care homes
Care Home Support Team Dementia Link Workers
Domiciliary care
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Peer group support and Personhood
County programmes: Memory café Singing for the brain Additional projects
Expert Patient Programme
Additional services commissioned locally, e.g. reminiscence, theatre and poetry – consideration of county roll out if appropriate
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Carer support
Carers Gloucestershire Carers’ Link Worker available to each practice
Carers self assessment via Community Dementia Nurse
Right to a full assessment of carers needs with Social Care, Care Services or 2gether Trust
Ongoing support from Dementia Advisor and Community Dementia Nurse
Managing Memory Together (ten practices) Catch up and Have your Say groups
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Data
PCCAG advice re standards/codes Programme for monitoring contracts Audit
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Sharing of patient information
Work to do: Primary care sharing with Community
Dementia Nurse Explore sharing between Primary
Care/Community Dementia Nurse/Dementia Advisor
Patient held records/health facilitation model Electronic sharing between agencies
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Information - patients and carers
Managing Memory Together Programme of information available Communications Manager post Dementia Advisor Media campaign Rolling programme of awareness raising Surgery Link – Carers Gloucestershire
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Education
Gloucestershire Training and Education Strategy for Dementia
Multi-agency learning Education programme for staff
E-learning www.kwango.com/gloucsdemlogin User Name: GPd Password: GlosDEM05
Development of dementia website www.dementiaawareness.co.uk
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What next?
Trials of model Visiting all Commissioning Clusters
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