STRATHMORE DEMENTIA SERVICE

The Journey So Far

Jim McGuinness, Project LeadKate Wright, Team Leader

Demographic & Area Covered

• Strathmore locality covers 424.4 square miles

• Population of approx 29,001

• 6,043 65+• Eurodem prevalence

389

At the Beginning

•14.9 WTE Nursing Staff•0.8 Admin•12 bedded unit•Average 34 patients admitted pa•Average 45% occupancy

•3 WTE CPN•1 Community Support Worker• 111 Legacy Caseload•Post Diagnostic Support

SDS Team

Consultant POA

2 WTE Team Leaders

3 WTE Band 6 Nurses

5.6 WTE Band 5 Nurses

5.9 WTE HCA

Dementia Advisors

Social Care Officers

1 WTE Occupational Therapist

Social Workers

ObjectivesTo provide opportunities for people living with dementia, who are showing symptoms suggestive of dementia with timely access to services for assessment, support and information earlier in the disease trajectory

To proactively plan and manage the needs of people living with dementia from the point of diagnosis, to provide continued care and treatment to maximise independence and support their stay in the community where it is safe to do so.

Proactive identification and assessment cognitive impairment in hospital inpatients who are physically unwell.

To improve the care and support delivered to people living with dementia in a care home.

Palliative and end of life care for people with dementia will be delivered with compassion and equity in a timely and person centred approach.

Lessons Learned• Induction / training and orientation of staff.• Clearly defining and agreeing performance

measures.• Defining roles within team.• Communication (public and stakeholders).• Phasing of implementation of project

objectives.• Adherence to project documentation and

governance systems.• Contingency planning.• Whole system impact.

Early Identification

• Process mapping and Care Pathway developed.

• Tiered Assessment process.• Open Access memory Clinics• Patient Experience / Satisfaction

completed.• One Practice Nurse and GP Unit

staff trained in Assessment Process.

Community support• Care Pathway Developed• Test of change – Joint Comprehensive

Case Planning• Patient / Carer focus group• Enhanced support provided in

community• Crisis intervention• Improved communication between

services• Links to Alzheimers Scotland Dementia

Advisors• Test of change - Befriending

Supported discharge

• Link Nurse to GP Unit • 39 Referrals received• Assessment training provided to GP

Unit nursing staff• HCA Stirling Dementia Unit training

being rolled out• Supported discharge• Enhanced liaison service in PRI

(Change Fund) – commencing 1 October 2011

Care Home Liaison

• Link nurse in 11 Care Homes• Information & Advice• Crisis intervention• Education & Training• PDSA – Zarat Burden Tool / NPI

End of Life Care• Current Liverpool Care Pathway

Future

• Review assessment process and Open Access Memory Clinics model

• Enhance post diagnostic support working with third sector specialist services

• Implement and evaluate Liaison service in PRI and improve supported discharge from GP Unit

• Review care home liaison role

Future

• Roll out Anticipatory Care Plans & Advanced Care Planning in Care Homes and in community

• Improve data collection tool• Improve communication with GPs• Patient / Carer digital stories• Establish joint Training and

Education Group to implement Promoting Excellence