1. STRATHMORE DEMENTIA SERVICE The Journey So Far Jim McGuinness, Project Lead Kate Wright, Team Leader

2. Demographic & Area Covered Strathmore locality covers 424.4 square miles Population of approx 29,001 6,043 65+ Eurodem prevalence 389

3. 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

4. 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

5. Objectives To 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.

6. 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.

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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