The Fife Dementia Strategy: 2010 â 2020 - The Knowledge Network

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The Dementia Advisor posts will each include part time administrative support (0.5 FTE). In order to prevent variable service use from occurring with the introduction of the Dementia Advisor, all physicians involved in the diagnosis of dementia will be well-versed on the service and how it can be accessed. Part of the Coordinators post will be to meet with local health and social care providers in the area they cover, to inform them of their post and to identify ways they can work together and provide services for people with dementia most effectively. The scope of the post will be broad and flexible, allowing the post holder to work in the most effective way to improve dementia services. As General Practitioners (GPs) are often the point of entry for a person with suspected dementia and are informed of every one of their patients who receives a diagnosis, the Coordinator will primarily work with them to promote awareness and understanding of dementia, and to ensure all individuals with a diagnosis are referred on to their service. All people who are diagnosed with dementia will be offered a referral to the Dementia Advisor from their GP as the primary point of referral. Referrals will be made immediately following diagnosis. The Advisor will remain with the person with dementia and their carers throughout the duration of their illness. Support and contact will be individualised and more intense during the first 10- 12 weeks following diagnosis and in agreement with the service users wishes, and will be gradually reduced. The support will remain available throughout the duration of their condition, and the carer and person with dementia can contact their Coordinator directly in the future. 94
APPENDIX 5: The Local and National Policy Context for the Fife Dementia Strategy Local Context Community Cares Framework - Single Outcome Agreement between Fife Partnership and the Scottish Government: Fife’s SOA identifies priorities and areas for improvement that will deliver better outcomes for the people of Fife. The SOA brings together the priorities of the Fife Community Plan and the contributions to the delivery of the outcomes by each of the Community Planning Partners. It focuses on the following four outcomes: educational achievement for all, tackling worklessness, conserving energy and resources, and keeping Fife connected. Dementia Integrated Care Pathway: The Fife Dementia ICP focused on achieving agreed outcomes for individual users of the services. They are a means of recording any variations from best practice and identifying and addressing gaps in the care of an individual. The ICP for dementia is based on best practice and helps to develop a multidisciplinary culture of continuous quality improvement for services and people who care for people with dementia and their families Living & Dying Well – Local Action Plan: A local implementation plan for the national action plan of Living & Dying Well. Long Term Conditions Collaborative: The Collaborative is designed to help people to deliver improvements in patient centred services and change the way care is provided for people with long term conditions such as dementia. The Collaborative focused on achieving sustainable improvements in the management of long term conditions across three work streams: Self Management, Condition Management, and Complex Care / Case Management. The Collaborative is designed to support NHS Boards and their partners to deliver a number of targets which involve the care and treatment patients with dementia. Mental Health Collaborative: The overall aim of the Mental Health Collaborative is to support NHS Fife to make the improvements needed to improve the quality of care received by people with mental health conditions, including dementia, by engaging in a culture of continuous improvement and service development in order to deliver against key national targets set out by the Scottish Government. This will involve linking into and leading on achieving dementia related NHS Health, Efficiency, Access and Treatment (HEAT) targets, including increasing the rates of diagnosis of dementia and earlier intervention. 95
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The Fife Dementia Strategy: 2010 -
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CONTENTS Foreword..................
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Executive Summary Dementia in Fife
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individuals who receive a diagnosis
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SECTION 1 Purpose & Scope of the St
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1.9 Due the complexity of the condi
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1.16 The Single Shared Assessment (
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involved in providing tailored care
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SECTION 2 Vision for Dementia Servi
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dementia specific learning resource
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equire a range of ongoing and short
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ecognise the symptoms and specific
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together to develop and utilise cur
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Following a diagnosis of dementia,
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development, have gone some way in
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detailed guide to disseminating inf
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psychoactive medicines have been sh
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online resources (3.3), and a singl
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services. This should be done once
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4.4 Supporting Carers AIM Implement
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with service providers and carers i
Page 47 and 48: 4.5 Housing AIM Support people with
Page 49 and 50: In order to ensure appropriate hous
Page 51 and 52: 4.6 Design for Dementia AIM To prov
Page 53 and 54: 4.7 Care at Home AIM Provide servic
Page 55 and 56: • The support of assistive techno
Page 57 and 58: 4.7.3 Improve joint working and com
Page 59 and 60: I’m not allowed to travel on my o
Page 61: Fife Council Supported Transport Se
Page 64 and 65: is referred on to a more appropriat
Page 67 and 68: 4.9 Short Breaks AIM Provide short
Page 69 and 70: example, many services provided for
Page 71: determining the quality of carer in
Page 74 and 75: incorrect prescribing, and more sui
Page 76 and 77: dementia. Prior to admission into c
Page 78 and 79: egular part of their daily care, an
Page 81 and 82: 4.11 Hospital & Acute Care AIM Peop
Page 83 and 84: 4.11.2 All people over the age of 6
Page 85 and 86: 4.12 Emergency Services AIM Emergen
Page 87 and 88: 4.13 Palliative & End of Life Care
Page 89 and 90: SECTION 5 Implementation & Delivery
Page 91 and 92: are the result of a series of small
Page 93 and 94: • a positive social environment t
Page 95 and 96: APPENDIX 2: Projected prevalence of
Page 97: APPENDIX 4: Dementia Advisor The fo
Page 101 and 102: Management of Patients with Dementi
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The Fife Dementia Strategy: 2010 â 2020 - The Knowledge Network