STRATHMORE DEMENTIA SERVICE The Journey So Far Jim McGuinness, Project Lead Kate Wright, Team Leader
Jan 05, 2016
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