Developments and progress

1. Developments and progress Dr Martin Freeman GP Clinical Lead for Dementia Services

2. Key issues • Raise awareness • Early diagnosis • Clear management of dementia as a LTC • Support that is available • Role of carers • Personhood • Information

3. Mapping the Pathway Diagnosis Assessment Management Planning Awareness and Identification Management of Long term condition Patient support Carer support End of life care

4. 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

5. 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

6. Mapping the Pathway Diagnosis Assessment Management Planning Awareness and Identification Management of Long term condition Patient support Carer support End of life care

7. 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?

8. 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

9. At time of diagnosis • Care plan • Community Dementia Nurse • Dementia Advisor • Information / education for patient and carer – (Managing Memory Together) • Treatment plan

10. Mapping the Pathway Diagnosis Assessment Management Planning Awareness and Identification Management of Long term condition Patient support Carer support End of life care

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Data • PCCAG advice re standards/codes • Programme for monitoring contracts • Audit

19. 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

20. 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

21. 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

22. What next? • Trials of model • Visiting all Commissioning Clusters • Please • Use the day • Use Feedback Forms • Keep talking!