Dementia Care Pathway - The future of Dementia Care for Counties

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Transcript of Dementia Care Pathway - The future of Dementia Care for Counties

Dementia Care Pathway

The future of Dementia Care for Counties Manukau

CONFIDENTIALITY

This document was written by Counties Manukau District Health Board and is under copyright to that

organisation. Others are welcome to make use of the document and material therein but the source should

be acknowledged.

2 | P a g e C M D H B D e m e n t i a C a r e P a t h w a y

FOREWORD Dementia is a devastating disorder of later life, having a profound impact on the person afflicted and all their

friends and family. With progressive and increasing disability caused by the condition, family members end up

playing a central role in providing care for the person with dementia, particularly in the latter stages of the

illness.

Dementia is a common condition in older people, in spite of which it is often poorly recognised and managed

by the community and by health services generally. With the ageing of the population structure, the number of

people suffering from the disorder is set to double in the next 15 to 20 years. Looking after those with

dementia is expensive the costs of care, including residential and private hospital care, and the costs imposed

on families are significant and set to increase. To date there has been no single or coherent service providing

care for those who suffer from dementia or supporting the families that care for them. Rather, people are

often assessed and managed in a multitude of different services, and many families feel that they do not know

who they should turn to in times of difficulty.

It has been the wish of many of those working with people with dementia and their families, to see the

creation of a dedicated care pathway devoted to this illness. There is a recognition that clear and early

diagnosis, long-term continuous management and, in particular, a commitment to providing support for those

families who care for people with dementia, will make a big difference to the quality of care provided to all

those with the illness. There is good evidence that good quality care improves the health of both those with

dementia and their families; there is also evidence that this can be provided in a cost-effective manner.

We are privileged to have been the sponsors of the project set up to address the issues around providing such

a Pathway. We are very grateful to all those who have contributed their time and expertise to the project and

brought it through to this stage. We hope to see their efforts rewarded, and to see the implementation of a

high quality dementia care service that will be available to all those people needing it in Counties Manukau.

Jenni Coles Director of Hospital Services

CMDHB

Dr Mark Fisher Clinical Head MHSOP

CMDHB

3 | P a g e C M D H B D e m e n t i a C a r e P a t h w a y

TABLE OF CONTENTS

FOREWORD ............................................................................................................................................................. 2

EXECUTIVE SUMMARY ........................................................................................................................................... 5

CHAPTER 1 .............................................................................................................................................................. 9

THE DEMENTIA CARE PROJECT .............................................................................................................................. 9

PROJECT OVERVIEW................................................................................................................................................. 9 LOCAL CONTEXT AND GENESIS OF THE PROJECT ........................................................................................................... 10 NATIONAL CONTEXT .............................................................................................................................................. 11 INTERNATIONAL CONTEXT ....................................................................................................................................... 12 THE PROJECT APPROACH ........................................................................................................................................ 14

1. Project Reference Group ......................................................................................................................... 14 2. Literature Review ..................................................................................................................................... 14 3. Clinical Files.............................................................................................................................................. 15

WORKSHOPS AND STAKEHOLDER PERSPECTIVES .......................................................................................................... 15 FOCUS GROUP FOR CARERS OF PEOPLE WITH DEMENTIA .............................................................................................. 16

THE COUNTIES MANUKAU LANDSCAPE ............................................................................................................... 19

CURRENT POPULATION AND DEMOGRAPHIC CHANGES ................................................................................................. 19 EXISTING CONTRACTED PROVIDERS IN COUNTIES MANUKAU AREA ................................................................................. 21

Specialist Services for Dementia Care .......................................................................................................... 21 General Services Supporting Dementia Care ............................................................................................... 23

CHAPTER 3 ............................................................................................................................................................ 25

THE DEMENTIA CARE PATHWAY: THE MODEL .................................................................................................... 25

DEMENTIA CARE PATHWAY VERSUS SERVICE .............................................................................................................. 25 MODEL OF SERVICE: KEY PRINCIPLES ......................................................................................................................... 26

1. Continuous Care ....................................................................................................................................... 26 2. Single Point of Entry ................................................................................................................................. 27 3. Linked Older Peoples Services ................................................................................................................. 27 4. Strong links with Primary Care ................................................................................................................ 28 5. Family and Carer focus ........................................................................................................................... 29

CHAPTER 4 ............................................................................................................................................................ 31

ELIGIBILITY FOR THE DEMENTIA CARE PATHWAY .......................................................................................................... 31 THE DEMENTIA CARE PATHWAY PHASES .................................................................................................................... 34

Phase One - Referral and Triage .................................................................................................................. 34 Phase Two Assessment and Diagnosis ...................................................................................................... 35 Community Follow-up .................................................................................................................................. 36

THE NAVIGATORS ROLE IS DIVIDED INTO THREE PHASES: ................................................................................................ 37 Phase Three: The Intensive Work ................................................................................................................ 37 Phase Four: Ongoing Community Care ........................................................................................................ 37 Phase Five: Aged Residential Care ............................................................................................................... 37

MILD COGNITIVE IMPAIRMENT ................................................................................................................................ 38 Roles of the Navigator ................................................................................................................................. 37

GROUPS FOR THOSE WITH DEMENTIA AND THEIR FAMILIES OR CARERS ............................................................................. 39 NEEDS ASSESSMENT AND SERVICES COORDINATION (NASC) ......................................................................................... 40 WHAT IS NOT PROVIDED BY THE DEMENTIA PATHWAY .................................................................................................. 40

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