Post-Diagnostic Support and Dementia Pathways Pathways and Post Diagnostic Support Dementia Task Group

Post Diagnostic Support – 5 Pillars Model

HEAT Target To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a link worker, including the building of a person-centred support plan. Can we achieve more than this?

Key areas of improvement What do we mean by ‘post-diagnostic support’ What is the current ‘pathway’: where are the gaps Appropriate support at the right time Challenges People with dementia and carers navigating the system themselves Poor communication between agencies, lacking coordination Inconsistent access to information and services

Identified work streams Implement effective joint working at local level Sector based Integrated multi disciplinary network ‘virtual team’ Creation of integrated pathways review of current services and practice build on current practice in NHS, CEC and voluntary sector to support people and their carers Continuum of Care Ensuring effective response and ongoing support from point of diagnosis

Virtual Team Integrated multi professional network local multi-disciplinary team Interagency case discussion Co-ordination of ‘named worker’ and reviews Ongoing development of services and best practice

Continuum of Care HEAT Target: Named Worker Role Provision of support and advice Right information at the right time Signposting to services Participation in local multi-disciplinary network

Early Intervention and Support Alzheimer Scotland Link Worker Model Training, line management and supervision provided by Alzheimer Scotland Distinct and clear remit Ensures city wide consistency Significant participation of third sector Access to national network Cost: (Alzheimer Scotland Salary Scale £23,544 - £26,064)

What do you think? Who else needs to be involved? How do we take this forward?