1. Camden Memory Service a new model
Sep 2016
Dr Suzanne Joels
Consultant Psychiatrist and Clinical Director SAMH

2. Dementia in Camden 1688* in Camden with dementia
1507 live in the community
181** live in a care home
1131/65.8 % have a diagnosis
Aim for 1266 (75%) diagnosed
*based on new calculations ** Camden Dementia Plan

3. Closing the gap(s) Memory service model is diagnosis dependent.
National move away from not only increasing diagnosis rate but also providing good quality post-diagnostic support.
Increasing body of evidence to suggest that CEIs are effective even in severe disease and if stopped lead to deterioration.
As the condition progresses, it is harder to manage you own care – no clear pathway for BPSD.
More likely to have co-morbid physical health problems.

4. Vision for Camden Memory service
To provide an assessment service for people with dementia
Initiation of medication
Post diagnostic support from diagnosis to death for all diagnosis
Tiered service depending on need
Skilled interventions delivered by qualified staff (nursing/OT/psychology) to people with BPSD who do not meet CMHT threshold
Closer links with GP practices to provide informal support and advice around dementia.
Therapeutic intervention for carers

5. New Model Aim to diagnose 1266 people with dementia
Review the person – not just the medication
Estimated caseload of 1085 (exclude care homes)

6. Camden – 3 localities, North (13 Practices), South (16 practices), West (6 practices)
Consultant lead
Band6
Band 5
1-2 Band 4
Consultant lead
Band6
Band 5
1-2 Band 4
Consultant lead
Band6
Band 5
1-2 Band 4

7. Staff
Band 4 Practitioners undertake majority of reviews and provide signposting, advice and support.
Band 4 Assistant Psychologists to offer START to carers and CST.
Band 5 Nurses to complete initial and 1st six months medication reviews, anti-psychotic reviews and provide advice and support Band 4s on any medication and health related queries.
Band 6 Nurses to review and offer interventions to patients with BPSD and other complexities, lead in key areas (i.e. Advanced Care Planning).
Band 6 Occupational Therapist to work purely in an OT specialist role.
Band 3 Support Worker role to become more of a clinical administrative role to keep up with increasing demand on admin.

8. ASC OT 3rd sector Death Decline
Regular review and signposting depending on need/risk
Intensive episode of care (Band 6)
Regular review depending on need/risk
Post diagnosis review
Decline
Move out od area or to 24 hr care
Psychology OT

9. Assessment
Scored outcomes at assessment and review, indicating direction of travel
a Maintaining physical and mental health
b Maintaining home and tenancy
c Planning for the future
d Financial
e Social Interaction and Relationships
Not yet collecting this data

10. “Contact Indicator” Risk Stratification
The tool is designed to ensure that those in contact with the DN service receive a consistently high level of service/ intervention that is based on need, risk and protective factors in place. Those service user who are at greatest risk of isolation, disengagement and breakdown will receive the most frequent and face-to-face contact. Service users who have substantial, robust networks of informal or statutory support services in place will have a proportionately reduced level of input
70% Green
30% amber
0% Red currently

11. Services/ Interventions
These are practical and non clinical
• lots of advice, lots of information, lots of answering question
• Expertise about what services are out there, how to access
• An understanding dementia, but with easy access to clinical experts
• Domestic safety, maintaining benefits and home
• Linking into other services
Working with Carers
Advanced care panning
Ongoing single point of contact – (until death, care home or the CMHT)

12. Benefits Clear pathway from diagnosis to death Continuity of care
Access to specialist support
One point of contact