Alzheimer Scotland Dementia Post Diagnostic Support ServiceEdinburgh

January 2014

Alzheimer Scotland Dementia Post Diagnostic Support Service

• Partnership Project Team – City of Edinburgh Council Health and Social Care, NHS Lothian and Alzheimer Scotland

• 6 Link Workers for 2 year fixed term through contract with Alzheimer Scotland (Change Fund)

• Started 9th December 2013 followed by period of induction with view to service start early January 2014

• Workers line managed by Alan Midwinter, Services Manager, Alzheimer Scotland

• Referral guidance circulated to staff January 2014

• Service in development

 

Why consider post diagnostic support in dementia?• Good practice

• Key element of Scotland’s National Dementia Strategy 2013-16

• HEAT target

HEAT Target

To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a link worker, including the building of a person-centred support plan.

Post Diagnostic Support – 5 Pillars Model

Alzheimer Scotland’s 5 Pillars model of support• Understanding the illness and managing

symptoms

• Peer support

• Supporting community connections

• Planning for future care

• Planning for future decision making

Post Diagnostic Support is not:

• Support for personal care

• Housing support

• A crisis intervention service

• Care management

Link worker role• Provide support and advice aligned to 5 pillars model• Act as link person from onset of diagnosis for 1 year• Give right information at the right time• Enable person and carer to be more informed and plan

their own pathway through dementia, including facilitating decisions and planning future care

• Signposting to services• Links with local professionals and community supports

so can advise from informed knowledge base• Report on HEAT target

Link workers aligned to the 4 Health and Social Care sectors and 2 Community Mental Health Teams

• North East – 1 link worker

• North West – 2 link workers

• South East – 1 link worker

• South West – 2 link workers

Staff have touch down bases in their local sector team office and the Memory Assessment Clinic at Marchhall (from early 2014)

Referral Guidance

• Newly diagnosed with a type of dementia from April 2013 and benefit from post diagnostic support, and

• the diagnosis has been confirmed through specialist assessment by a doctor.

Referral Pathway for Post Diagnostic Support

Alzheimer Scotland Link Worker Service - Referral screened, in liaison with other professionals if required, to decide if the Post Diagnostic Support Link Worker is most appropriate person to be involved or whether

referral should be re-directed for more specialist assessment and support.

Record screening decision

GP ,referrer and person referred notified of decision

Diagnosis of dementia confirmed following specialist assessment by doctor.

Complex/ higher level mental health needs/ social care needs

or advanced dementia that requires more specialised assessment and support

Non complex or early stages of dementia and benefit from PDS.

Consent given from person to be referred

Alzheimer Scotland Post Diagnostic Support Link

Worker Service

Community Mental Health Team

Allocated to Alzheimer Scotland Post Diagnostic Support Link Worker

Health and Social Care Team

Person known – no diagnosis. Requires referral for further

medical/psychiatric assessment.

GP – for further assessment/refer on for

further specialist assessment

Consent Consent to refer and share information during Alzheimer

Scotland Link Worker involvement with other organisations an important element of partnership working. Consent needs to be recorded.

Consent required for:– Referral to Post Diagnostic Support Service– At point of first contact between Link Worker and person

and/or carer to share information between Alzheimer Scotland, NHS Lothian and CEC Health and Social Care staff

Links to other work

• Life Planning Campaign (raise awareness of dementia and decrease stigma associated with dementia)

• Dementia Friendly Communities

• North West Edinburgh Partnership Pilot