Post-Diagnostic Support and Dementia Pathways

Pathways and Post Diagnostic SupportDementia Task Group

Post Diagnostic Support – 5 Pillars Model

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.

Can we achieve more than this?

Key areas of improvement

• What do we mean by ‘post-diagnostic support’• What is the current ‘pathway’: where are the gaps• Appropriate support at the right time

Challenges• People with dementia and carers navigating the system

themselves • Poor communication between agencies, lacking

coordination• Inconsistent access to information and services

Identified work streams

Implement effective joint working at local level• Sector based Integrated multi disciplinary network ‘virtual team’

Creation of integrated pathways• review of current services and practice• build on current practice in NHS, CEC and voluntary sector to

support people and their carers

Continuum of Care • Ensuring effective response and ongoing support from point of

diagnosis

Virtual Team

Integrated multi professional network• local multi-disciplinary team• Interagency case discussion • Co-ordination of ‘named worker’ and

reviews• Ongoing development of services and

best practice

Continuum of Care

HEAT Target: Named Worker Role• Provision of support and advice• Right information at the right time• Signposting to services• Participation in local multi-disciplinary network

Early Intervention and SupportAlzheimer Scotland Link Worker Model

• Training, line management and supervision provided by Alzheimer Scotland

• Distinct and clear remit• Ensures city wide consistency• Significant participation of third sector • Access to national network• Cost: (Alzheimer Scotland Salary Scale £23,544 - £26,064)

What do you think?

Who else needs to be involved?

How do we take this forward?