Dementia on the Isle of Wight

Dementia on the Isle of Wight
Dr Michele Legg
GP Tower House Surgery
CCG Clinical Lead for Frail Elderly and
Wessex AHSN Lead in Dementia
What am I going to share:
• Improving Early Diagnosis of Dementia
• Development a single Dementia pathway to
provide fully holistic care and high quality post
diagnostic support
• Continued improvement in Dementia
diagnosis rates
• Living well with Dementia on the Isle of Wight
Dementia on the IOW
• 24% of the population on the IOW are over
65 years of age
• 65% diagnosis rate June 2014
How have we achieved this:
• GP communication, training and support
• Awareness campaigns driven by Dementia
Steering Group
The Dementia Integrated Care
Which includes:
• Referrals from GP /Hospital based dementia liaison
• Post diagnosis counselling support and advice following
diagnosis 8 week intensive CBT and 24 week
maintenance CBT with additional community memory
• Dementia intensive team offer advice and support in
the community
• A new ward based on Dementia friendly Environment
Dementia Care Pathway (Cluster 18/19)
Primary Care/Other
NHS Trust (Memory Service)
Community Services
Local Authority
Suspected Dementia/Re-referral to Memory Service
(or End of Pathway as discharged back to GP)
Referral from:
GP/Hospital Screening
Other Primary/Secondary professional*
Self referral*
From carer or relative*
Local Authority or Voluntary Sector*
*With GP and/or patient consent
Community Support Services
Self-referral route
Assessment and Diagnosis of Dementia
Memory Service: IW NHS Trust
Individual or Group sessions (subject to level of need but to encompass as below)
To encompass (aligned to Care Plan*) (list not exhaustive):
· Signs & symptoms of dementia; Course & prognosis of the condition; Carers support services;
Treatments; Local care and support services; Support groups; Medication review;
Sources of financial and legal advice, and advocacy; Medico-legal issues, including driving
Local information sources, including libraries and voluntary organisations
Ongoing cognitive and maintenance interventions
Community Memory Groups: AGE (UK) IW
Long term CST support subject to eligibility
* NICE guidance (for Information)
CARE PLAN : Care plans should be based on an assessment of a person’s life history, social & family circumstance, and preferences, as well as their physical
and mental health needs and current level of functioning and abilities.
COORDINATED HEALTH & SOCIAL CARE (H&SC): Services for people with dementia should be delivered in a coordinated manner and involve:
A combined care plan agreed by H≻ Assignment of named health and/or social care staff to operate the care plan; Endorsement of the care plan by the person
with dementia and/or carers and Formal reviews of the care plan at an agreed frequency.
Other Services
24 x 1hr per/wk (Group Sessions)
During this period: If appropriate, progress to ‘Ongoing cognitive and maintenance interventions’. But at this stage
discharge to GP with Care Plan (copy of Care Plan given to person with dementia and their carer) with details of
continuing points of contact and interventions to support person’s wellbeing, as well as arrangements for follow-up
by GP and re-referral to Memory Service.
Alzheimer’s Society - Dementia Advisory Service
Interventions for maintenance of function: Maintenance CST
Community Wellbeing and Social Care Services (Riverside): IW Council
Individualised information & signposting service, Circles of Support,
An extended information & signposting service to immediate carers, families and friends
16 group sessions x 2 hours
(up to 8 people per group)
During this period: Discharge planning, Care Plans reviewed,
Contingency Plan and List of Support Networks
Dementia Challenge Fund and S256 services
Cognitive Stimulation Therapy (CST)
Interventions for cognitive symptoms
Memory Service: IW NHS TRUST
e.g. Adelaide/Goulding Day Care, Carers Support Service, Riverside, Stroke Club, Friendships Groups, AGE (UK) IW, Alzheimer’s Society, Quay
Carers Support, Sing About
Post Diagnosis Support
Memory Service: IW NHS Trust
These services can be accessed during this flow at any time and include services to help people with dementia, their carers, families, friends as well as
professionals e.g. Information & Advice, Dementia Awareness Training. Provided by Alzheimer’s Society, Alzheimer Cafes and AGE (UK) IW.
Transition: Refer to specialist intervention/GP if dementia deteriorates e.g. moves to Cluster 20/21
Discharge: If deceased/exit service
Refer to GP and/or other
appropriate service
Triage and Assessment
Recognition, Investigation & Sub-Type
Dementia Alliance
• IOW CCG led the formation of a Dementia Alliance
• IOW Age UK working with the memory service to expand
the capacity of the groups and offering 1:1 volunteering
support in the home
• Alzheimer's Society raising awareness of dementia and
other support services for members of the public and
health professionals, providing dementia support
• Alzheimer Cafe UK providing social space for people with
dementia and their families
Other projects include
• Dementia Awareness Training (DARC)
• Dementia Friendly hospital:
St Mary’s Hospital -The butterfly scheme
Acute Wards Dementia Champion Programme
Dementia friendly environments
Raising awareness of dementia and increasing information and
support – awareness days and drop in sessions
– St Marys Volunteer CST programme
Care Navigators
Circles of Support
Dementia Friendly Environments in Care Homes
Dementia Road Map
Dementia Friendly Communities
• CCG with DoH investment commissioned Age
UK to pilot developing dementia friendly
• Excellent example of community asset
development with input from local people
with Dementia
Dementia Friendly Ryde Pilot
Tower House GP
Wightlink &
• Safe-haven
• Dementia awareness training for all
• Staff uniforms changed to bright pink
• Dementia awareness training for Ryde
based staff
Ryde Library
Ryde School
• Resource section of library
• Tickets for those with memory loss
(ie) remove fines
• Memory Group taster sessions &
Reminiscence workshops
• Assembly with Year 11, 12 and 13
• Year 9 Dementia awareness
workshops as part of PHSE
Creating a Dementia Friendly
Operation Serenity
Safety Net
• Improve Police responses to
mental health crisis calls
• Mental Health workers attend
calls with Police
• Online information hub for Police
and Fire & Rescue Services
• Informs services they are being
called to assist an individual with
Banks and Shops
Safe Journey Cards
• Communication Advice Sheet
circulated to staff to help
improve services to those with
• Distributed via Memory Service
• Inform driver that passenger has
Dementia and may require
additional support in travelling
What’s next:
• Continue developing a dementia friendly
hospital and supporting culture change
• Review crisis team pilot to support for 72
• Implementation of Islands Dementia Strategy
Action Plan
• Review of the Dementia Pathway
• Dementia Friendly Isle of Wight