1. 1 Dementia Care Health Partnerships Division Nottingham North and East Adult Integrated Community Services

2. 2 Dementia Care Health Partnerships’ Response  Recognising the need to support staff in identifying the early signs of dementia: education for staff use of identification tool (MoCA) support for family members and carers working with and learning from colleagues across organisations  ‘Providing seamless and holistic health care to patients in their own home (including care homes) which is patient centred, wrapping around service provision to make it meaningful for the patient’.  NNE Service specification April 2016

3. 3 Dementia support in NNE  ‘RAG rating’ Matron managing complex patients (RED)  Attend daily hand over meetings  ‘In house’ MDT’s every week  ‘In house’ MDT’s monthly with community geriatrician  GSF/At Risk meetings in GP practices  Matron role has developed into a link with/between AIT, SSD, IRIS, MHSOP, voluntary agencies, acute services and family/friends  Involves case management incorporating principles from recovery and frailty programs (self care and personal goals)

4. Patient scenario  THE PATIENT Complex PMH with physical and mental health needs as well as dementia  BEHAVIOURS Challenging  THE CARE TEAM Community Team Social care package Housing Services  SELF CARE SPECIALISTS CMHT (IRIS)  OUTCOME Admitted to hospital and onto care home

5. 5 Future Challenges & opportunities  Increasing numbers of people with dementia in their own homes  Need to work within current financial resources  Greater numbers of complex patients being managed in the community  A proactive approach to self care and family involvement  Keep channels of communication open  Multidisciplinary working/reduce duplication