Measuring Improvements and Communicating Change

It is extremely important that we understand the impact of our strategy on the outcomes that people with dementia experience. We will therefore put arrangements in place to oversee this process. These include:-
  • The continuation of a Dementia Managed Clinical Network to take forward changes in clinical practice and to oversee the implementation of agreed actions within the dementia strategy, including the development of agreed measures and timescales to report on the impact of the Strategy
  • Quarterly reporting to the IJB’s Strategic Planning Group on the implementation of the Strategy
  • Wider reporting of measures which support dementia care, through mainstream IJB and Health Board performance reporting

Communicating Change

Good communication with staff, stakeholders and communities will be fundamental to the process as we change our service and support arrangements over the next few years.

To that extent, we are committed to:-

  • Providing regular updates, newsletters, media articles and blogs that can be disseminated to inform people about our work
  • Hosting regular staff meetings to allow for feedback about the changes we’re introducing, including engagement with service users
  • Update reports to Comhairle committees and the NHS Board to ensure that both parent organisations are kept up-to-date with the implementation of the strategy
  • Contributing to Locality Planning Groups and to public engagement sessions about programmes of change.

 

Objective

Actions

Lead

Impact

Risk reduction

Embed a whole life approach to dementia prevention on the risk factors in four key domains: developmental,

psychological and psychosocial,

lifestyle and

cardiovascular risk factors.

 

Raising awareness with people who have a long-term condition around the risk factors which can lead to the development of dementia

 

Targeting of smoking cessation to those in areas of deprivation and those at highest risk of developing dementia

 

Aim  to reduce overall consumption of alcohol

 

 

 

Awareness campaign about the benefits of physical activity and risk factors associated with obesity

 

Promoting access to secondary and

further education to support the development of a second language and/or music, which are protective factors against developing dementia

 

Increase opportunity for cognitive activity such as group discussion and book clubs in later life, both pre and post diagnosis

 

 

MCN Leads

 

 

 

 

Director of Public Health

 

 

Director of Public Health

 

 

 

Director of Public Health

 

 

Spiritual care  or Public health

 

 

 

 

NHS Head of Planning and development

 

 

Improved detection and treatment of diabetes and hypertension

 

 

Reduced risk factors for brain injuries due to vascular damage

 

Reduction in alcohol related dementia including Korsakoff’s psychosis

 

Reductions in population level of obesity

 

 

Increased levels of bilingualism

 

 

 

 

Improved resilience

 

 

 

 


 

Objective

Actions

Lead

Impact

 

Provide equitable access, standards and services for disadvantaged groups.

Include care provision for people with Young Onset Dementia in care pathways

 

 

Implement Dementia screening programme for people with learning disabilities as part of wider healthcare support

 

 

Develop information and advice to those with dementia from LGBT groups and communities

 

All service providers will evidence awareness training of the needs of BME groups and communities

 

Provide translator facilities for people with dementia if English is not their first language

 

 

Provide accessible information for people who have sensory impairments

 

Nurse Consultant Older people and dementia

 

Associate Director of Mental Health and Learning Disabilities

 

Director of Public Health

 

 

 Spiritual care lead

 

 

 

Spiritual care lead

 

 

 

Spiritual care lead

 

 

 

 

Clear pathway to support and assist

 

 

Effective monitoring of high risk individuals

 

 

 

Reduced isolation and improved awareness

 

 

Equality and diversity needs met

 

 

Facilitates holistic and person centred assessment

 

Physical impairments are no impediment to information


Diagnosis and Post-diagnostic Support

 

Objective

Actions

Lead

Impact

 

Continue improvement for dementia diagnosis rates to facilitate earlier diagnosis and uptake of post diagnostic support

 

Introduce Primary Care diagnostic service based on accredited assessment tools which meets target time of 4 weeks for first appointment

 

 

Utilise the Primary Care Transformation Fund to pilot change of model.

 

 

 

Support team approach to community diagnostic service across localities in primary care

 

 

Review the effectiveness and sustainability of innovative models around diagnosis within Primary care

 

 

Raise awareness of benefits of early diagnosis to encourage assessment and planning for the future

 

Nurse Consultant Older people and dementia

 

 

 

Nurse Consultant Older people and dementia

 

 

Nurse Consultant Older people and dementia

 

 

 

 

 

 

 

 

 

Nurse Consultant Older people and dementia

 

 

Nurse Consultant Older people and dementia

 

Reduce barriers to access for memory assessment and reduce anxiety about process of diagnosis

 

 

Strengthens primary care interface with people affected by cognitive impairment

 

Equality of access to all localities

 

 

 

Promote inclusion

 

 

 

 

Earlier diagnosis for service planning and people supported to self-manage in all localities

 

 

 

 

Objective

Actions

Lead

Impact

 

Diagnosis and Post-diagnostic Support

Ensure quality and consistency of post-diagnostic support for every person diagnosed with dementia

 

Develop, implement and distribute new criteria around accessing post-diagnostic services

 

 

Ensure continuity of support from primary care led diagnosis to post-diagnostic services

 

 

 

Embed specialist drug treatments for dementia in Primary Care

 

 

 

Introduction and embedding of Alzheimer Scotland 5 pillars model for PDS (see Appendix 1) across localities, ensuring Power of Attorney is considered by every person with dementia who retains capacity

 

 

Post-diagnostic support will be available for every individual until they are no longer able to self-manage

 

 

 

Nurse Consultant Older people and dementia

 

 

Nurse Consultant Older people and dementia

 

 

Nurse Consultant Older people and dementia/Associate Medical Director

 

Nurse Consultant Older people and dementia

 

 

 

 

Nurse Consultant Older people and dementia

 

Ensures compliance with best practice in promoting independence

 

 

Getting a diagnosis and accessing post-diagnostic support is easier and less daunting

 

Treatment and care of people with dementia is focused in primary care

 

 

Ensures consistency of service for benchmarking and ongoing delivery, Reduces need for Guardianship applications

 

 

Continuity of care and reduced crisis presentations

 

 

 

Objective

Actions

Lead

Impact

 

Diagnosis and Post-diagnostic Support

Ensure quality and consistency of post-diagnostic support for every person diagnosed with dementia

 

Use waiting times and post diagnostic support (PDS) criteria to  monitor and evaluate the effectiveness of PDS services

 

 

 

Align post-diagnostic services to Primary Care

 

 

 

Post-diagnostic support will be available for every individual until they are better supported by the Alzheimer Scotland 8 pillars model of community support (see Appendix 2)

 

Nurse Consultant Older people and dementia

 

 

 

Nurse Consultant Older people and dementia

 

 

Nurse Consultant Older people and dementia

 

Ensures complete compliance with best practise in promoting independence

 

 

Getting a diagnosis and accessing post-diagnostic support is easier and less daunting

 

Continuity of care and reduced crisis presentations

 

 

Care and Support

Care and support

People with dementia will be supported fully to remain at home and be fully involved in their communities

Develop a range of intermediate care options to respond to health changes which maximises resilience and promotes independence

 

 

Implement Alzheimer Scotland’s “8 Pillars” model to ensure holistic care coordination across statutory and non-statutory services

 

 

 

Embed anticipatory care planning for people who live at home with a range of long-term conditions including dementia

 

 

 

Encourage communities to develop local response to reduce social isolation

 

 

 

We will consider what local action is required to support further improvements in transport for people with dementia

 

Ensure access to a wide range of psychological therapies for people affected by dementia

Head of Locality Services

 

 

 

 

Chief Officer, IJB

 

 

 

 

 

Lead Nurse

 

 

 

 

 

Head of Health Intelligence

 

 

 

Branch manager, Alzheimer Scotland

 

 

Consultant Clinical Psychologist

 

Reduction in avoidable admissions to the acute hospital settings and delays in discharge

 

 

Coordinated holistic care for people in a more advanced stage of the disease supports care at home

 

Strong community and primary care responses to the health needs of people with dementia

 

 

Communities strengthened

 

 

 

 

Reduced social inclusion

 

 

 

Increased well-being of people with dementia and carers

 

 

Objective

Action

Lead

Impact

 

Care and Support

 

Home environments will be safe and supportive with the maximisation of adaptations and assistive technology

Plan in partnership with people affected by dementia, their broader housing and accommodation needs.

 

 

In partnership with housing providers, agree prioritisation of adaptations as detailed in the online guide Improving the Design of Housing to assist People with Dementia.

Promote telecare, aids and adaptations for people with dementia by embedding in PDS.

 

 

Post diagnostic support for early diagnosis includes future permissions for the range of assistive aids that could be used to help with  safety such as GPS trackers

 

Promote the therapeutic and enabling role of Allied Health Professionals in community settings

 

 

 

 

 

 

 

 

Head of Partnership Services

 

 

 

Head of Partnership Services

 

 

 

Nurse Consultant Older people and dementia

 

Nurse Consultant Older people and dementia

 

 

Lead AHP

 

Most people with dementia can stay at home and be involved in their communities.

 

Maintain the independence and quality of life of people with dementia and their carers.

 

Cost-effective adaptation of housing for people with dementia

 

Assistive aids that help with safety are fully in line with individual consent.

 

 

Multi-disciplinary approach to care at home

 

 

Objective

Actions

Lead

Impact

 

 

 

Provide integrated care and support on the basis of the 8 Pillars model

Consult on local Integrated Care Pathway and disseminate agreed pathway widely

 

Nurse Consultant Older people and dementia

 

Raised awareness and service planning structure identified

 

Care and Support

 

 

Respond to Stress and Distress with psychological support

To  ensure anti-psychotic medication is used appropriately, benchmarking level of prescribing across all sectors

 

Introduce risk assessment and review protocol for initiation of antipsychotics for people with dementia for all prescribers

 

Develop reporting tool for prescribers to identify numbers and patterns for use of antipsychotics

 

Develop and embed a training plan for stress and distress to front line staff across all sectors

 

 

 

 

 

Nurse Consultant Older people and dementia

 

Associate Medical Director

 

 

Associate Medical Director

 

 

Consultant Clinical Psychologist

 

Meet national strategy guidelines on reduction of use

 

Manage patient safety effectively

 

 

Ensure overview of prescribing activity and promotion of alternatives

 

Wide range of staff trained to use non pharmacological interventions for S&D

 

 

 

 

 

 

 

 

 

 

Objective

Actions

Lead

 

Impact

 

Continue improvement in acute and specialist dementia health and social care settings

 

Use programme of inspections into older people’s care in acute hospitals by Healthcare Improvement Scotland to effectively drive change and prioritise action areas

 

Benchmark against the 10 Point National Action Plan and develop detailed plan to meet all standards by 2020 (Appendix 4)

 

 

 

 

Effective discharge is fully supported by the required range of community services within a maximum of  72 hours of being fit for discharge

 

 

Develop Alzheimer Scotland Allied Health professional role to support Alzheimer Scotland Advanced practice model

 

 

 

 

 

 

Hospital Manager

 

 

 

 

 

Director of Nursing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head of Partnership Services

 

 

 

 

Lead AHP

 

Standards of Care for Dementia in Scotland are met

 

 

 

When admission to hospital is unavoidable for people with dementia, the care experience is safe, coordinated, dignified and person-centred.

 

Discharges from hospital are safe and timeous

 

 

 

 

Increased leadership in dementia at expertise level

 

 

Objective

Actions

Lead

Impact

 

Care and Support

 

Care and Support

Care and Support

 

Identify and promote the specific issues and

needs of the dementia client group in residential care

Introduce and embed routine screening of admissions and at annual reviews of people living in care settings

 

Introduce case management in residential units with identified responsible professional

 

Include multi-disciplinary approaches to dementia in residential care within the Integrated Care Pathway

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head of Social and Partnership Services

 

 

Head of Social and Partnership Services

 

 

Nurse Consultant Older people and dementia

Diagnosis of dementia and optimisation of interventions

 

Equity of case management provision

 

Increase knowledge of response to stress and distress in care homes and elsewhere

 

 

 

 

Objective

Actions

Lead

Impact

Care and Support

 

Implement and extend Promoting Excellence dementia health and social services training and embed dementia in the education plan for all employees and volunteers

 

Workforce development plans for  statutory services identifies the level of Promoting Excellence that all posts require and are assessed annually

 

Prioritise training for staff who require the Enhanced level of Promoting Excellence training

 

Provision of Promoting Excellence training and awareness raising in other areas of public life including schools and community groups

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nurse Director

 

 

 

 

Nurse Director

 

 

 

Nurse Consultant Older people and dementia

 

All staff have adequate skills and knowledge to support people.

 

 

Staff are more confident and better aware of when to seek specialist advice.

 

Reduction of stigma supports early assessment and ongoing support in communities

 

Objective

Actions

Lead

Impact

Palliative care

Respond proactively to the overall palliative and end of life care needs of people with dementia

 

Promote advanced care planning based on the wishes of the individual and taking account of carers’ views

 

Develop a care pathway for palliative and end of life care that effectively supports the individual to a good life and a good death

 

Introduce and embed policies and procedures to promote best practice in end of life care with capacity assessments and Do Not Attempt Cardiopulmonary Resuscitation decisions

 

Develop a workforce skilled in end of life care by use of national improvement programmes

 

 

Develop a specialist dementia workforce to support Alzheimer Scotland Advanced Care service model with obligate network if required to enhance provision (Appendix 3)

 

Lead Nurse, IJB

 

 

 

Chief Officer, IJB

 

 

 

Lead Nurse

 

 

 

 

 

Chief Officer, IJB

 

 

 

Consultant Clinical Psychologist

 

Ensures compliance with incapacity legislation 

 

 

Reduced variation for all conditions in remote settings

 

 

Greater awareness of agreed procedures for making decisions for people with dementia who lack capacity

 

 

Generalist palliative skills are available across all localities

 

 

Specialist and generalist palliative skills are available across all localities