Dementia on the Isle of Wight Dr Michele Legg GP Tower House Surgery CCG Clinical Lead for Frail Elderly and Dementia Wessex AHSN Lead in Dementia What am I going to share: • Improving Early Diagnosis of Dementia • Development a single Dementia pathway to provide fully holistic care and high quality post diagnostic support • Continued improvement in Dementia diagnosis rates • Living well with Dementia on the Isle of Wight Dementia on the IOW • 24% of the population on the IOW are over 65 years of age • 65% diagnosis rate June 2014 How have we achieved this: • GP communication, training and support • Awareness campaigns driven by Dementia Steering Group The Dementia Integrated Care Pathway Which includes: • Referrals from GP /Hospital based dementia liaison team • Post diagnosis counselling support and advice following diagnosis 8 week intensive CBT and 24 week maintenance CBT with additional community memory groups • Dementia intensive team offer advice and support in the community • A new ward based on Dementia friendly Environment principals Key: Dementia Care Pathway (Cluster 18/19) Primary Care/Other NHS Trust (Memory Service) Community Services Local Authority Suspected Dementia/Re-referral to Memory Service (or End of Pathway as discharged back to GP) Referral from: GP/Hospital Screening Other Primary/Secondary professional* Self referral* From carer or relative* Local Authority or Voluntary Sector* *With GP and/or patient consent Community Support Services Self-referral route Assessment and Diagnosis of Dementia Memory Service: IW NHS Trust NO Diagnosis? YES Individual or Group sessions (subject to level of need but to encompass as below) To encompass (aligned to Care Plan*) (list not exhaustive): · Signs & symptoms of dementia; Course & prognosis of the condition; Carers support services; · · · Treatments; Local care and support services; Support groups; Medication review; Sources of financial and legal advice, and advocacy; Medico-legal issues, including driving Local information sources, including libraries and voluntary organisations Ongoing cognitive and maintenance interventions Community Memory Groups: AGE (UK) IW Long term CST support subject to eligibility * NICE guidance (for Information) CARE PLAN : Care plans should be based on an assessment of a person’s life history, social & family circumstance, and preferences, as well as their physical and mental health needs and current level of functioning and abilities. COORDINATED HEALTH & SOCIAL CARE (H&SC): Services for people with dementia should be delivered in a coordinated manner and involve: A combined care plan agreed by H&SC; Assignment of named health and/or social care staff to operate the care plan; Endorsement of the care plan by the person with dementia and/or carers and Formal reviews of the care plan at an agreed frequency. Other Services 24 x 1hr per/wk (Group Sessions) During this period: If appropriate, progress to ‘Ongoing cognitive and maintenance interventions’. But at this stage discharge to GP with Care Plan (copy of Care Plan given to person with dementia and their carer) with details of continuing points of contact and interventions to support person’s wellbeing, as well as arrangements for follow-up by GP and re-referral to Memory Service. Alzheimer’s Society - Dementia Advisory Service Interventions for maintenance of function: Maintenance CST Community Wellbeing and Social Care Services (Riverside): IW Council Individualised information & signposting service, Circles of Support, An extended information & signposting service to immediate carers, families and friends 16 group sessions x 2 hours (up to 8 people per group) During this period: Discharge planning, Care Plans reviewed, Contingency Plan and List of Support Networks Dementia Challenge Fund and S256 services Cognitive Stimulation Therapy (CST) Interventions for cognitive symptoms Memory Service: IW NHS TRUST e.g. Adelaide/Goulding Day Care, Carers Support Service, Riverside, Stroke Club, Friendships Groups, AGE (UK) IW, Alzheimer’s Society, Quay Carers Support, Sing About Post Diagnosis Support Memory Service: IW NHS Trust These services can be accessed during this flow at any time and include services to help people with dementia, their carers, families, friends as well as professionals e.g. Information & Advice, Dementia Awareness Training. Provided by Alzheimer’s Society, Alzheimer Cafes and AGE (UK) IW. Transition: Refer to specialist intervention/GP if dementia deteriorates e.g. moves to Cluster 20/21 Discharge: If deceased/exit service Refer to GP and/or other appropriate service Triage and Assessment Recognition, Investigation & Sub-Type Dementia Alliance • IOW CCG led the formation of a Dementia Alliance • IOW Age UK working with the memory service to expand the capacity of the groups and offering 1:1 volunteering support in the home • Alzheimer's Society raising awareness of dementia and other support services for members of the public and health professionals, providing dementia support workers • Alzheimer Cafe UK providing social space for people with dementia and their families Other projects include • Dementia Awareness Training (DARC) • Dementia Friendly hospital: – – – – St Mary’s Hospital -The butterfly scheme Acute Wards Dementia Champion Programme Dementia friendly environments Raising awareness of dementia and increasing information and support – awareness days and drop in sessions – St Marys Volunteer CST programme • • • • Care Navigators Circles of Support Dementia Friendly Environments in Care Homes Dementia Road Map Dementia Friendly Communities • CCG with DoH investment commissioned Age UK to pilot developing dementia friendly communities • Excellent example of community asset development with input from local people with Dementia Dementia Friendly Ryde Pilot Tower House GP Surgery Wightlink & Hovertravel • Safe-haven • Dementia awareness training for all staff • Staff uniforms changed to bright pink • Dementia awareness training for Ryde based staff Ryde Library Ryde School • Resource section of library • Tickets for those with memory loss (ie) remove fines • Memory Group taster sessions & Reminiscence workshops • Assembly with Year 11, 12 and 13 students • Year 9 Dementia awareness workshops as part of PHSE Creating a Dementia Friendly Island Operation Serenity Safety Net • Improve Police responses to mental health crisis calls • Mental Health workers attend calls with Police • Online information hub for Police and Fire & Rescue Services • Informs services they are being called to assist an individual with Dementia Banks and Shops Safe Journey Cards • Communication Advice Sheet circulated to staff to help improve services to those with Dementia • Distributed via Memory Service • Inform driver that passenger has Dementia and may require additional support in travelling What’s next: • Continue developing a dementia friendly hospital and supporting culture change • Review crisis team pilot to support for 72 hours • Implementation of Islands Dementia Strategy Action Plan • Review of the Dementia Pathway • Dementia Friendly Isle of Wight Questions…..
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