Integrating Care in Eastern Cheshire

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What is the Dementia Reablement Service

• 12 month pilot

• Funded through the Better Care Fund

• Liverpool John Moores University are evaluating the pilot

• Performance data and case studies to measure impact

• Action learning with the DRS teams & Customers

• The service will develop based on the input from Customers, LJM and the Reablement Team

Why do we need to provide additional support?

• Identified that there was a clear gap in post diagnostic support for individual and carers living with dementia

• 5,000+ people in Cheshire East living with Dementia

• The number of people aged 65 or over living with dementia in Cheshire East is expected to rise by more than 40% by 2030

Identified outcomes for customers accessing the DRS

• To lead full and active lives

• Able to remain in their own home for longer

• Develop skills to manage the challenges of living with dementia

• Increased confidence and self-esteem

• Reduced feeling of social isolation

• Improved emotional well-being

• Ensure Legal & financial arrangements in place

How will the service do this?

Provide a short-term personalised service to the individual with dementia and their carer:

• Visit individual and carer, and get to know them• identify what is concerning them in relation to their

dementia• identify what people need help and support with in

relation to their dementia• provide information on local dementia services and

dementia friendly activities• provide a personalised action plan

Eligibility Criteria:

Individual must have a diagnosis and be in the early stages of Dementia

Referral Route:• Memory Clinics• GPs• Social Care teams• Self referral

Improving Integration

1. The service has been jointly commissioned by health and social care

2. Close working with Memory Clinics to establish a simple, easy to manage referral process- ensuring a timely and appropriate referral

3. GP buy in- the service has presented to GP and Nurse groups and will continue to work with identified GP leads to ensure the service is accessed by all practices across the Borough

4. Working closely with social care teams and the End of Life team to support people to plan their support and care for the future, arranging additional care and support where appropriate

5. The service is part of the wider dementia strategy designed to ‘join up’ support for individuals and carers

6. Working closely with VCFS organisations such as AGE UK and The Alzheimer's Society

Improving the Journey for Customers and their Carers

1. Creation of a Service Reference Group to inform how the service is delivered in the future

2. Service summary letter will be sent to the persons GP to inform the GP of the individuals support plan, and the outcomes that person has achieved

3. The DRS team are using a shared care notes system with Memory Clinics, this will ensure professionals are fully informed about an individuals case history

4. Due to the good working relationship with Age UK and Alzheimers, the service is able to signpost customers to these services for ongoing support

What next

1. Continue to develop a single pathway following diagnosis will support individuals and their carers to manage better and reduce stress and confusion of multiple contacts with the health & social care system

2. To identify any unmet need/ demand from individuals and carers

3. Further develop the service to ensure that the needs of people using the service are at the centre of service planning