Cabrini Community Cognition & Dementia Service (CCDS) – A Private

Health Model of Care

Sally Howe - Director Business &

Service Development

Market Overview

Current trends driving Innovation • Ongoing consumerisation of healthcare

• Emphasis on outcomes and value based purchasing

• Strategies to improve care coordination

• Hospital and community partnerships to drive changes in behaviors

Strategy

• The Mission – respond to unmet need

• The Market

• The Gap

• Partnerships and Collaboration

Cabrini Capability

Cognition and Dementia Clinic

Rehabilitation Services

Palliative Care Services

Residential Aged Care

Chronic Disease Programs

Home Based Rehabilitation

Private Allied Health Clinics

Allied Health Inpatient Services

Patient Experience Team

Cabrini Community Cognition & Dementia Service (CCDS) – A Private

Health Model of Care

Dr Luke Smith – Clinical Neuropsychologist

& Clinical Lead for CCDS

Clinical Practice Guidelines

‘The quality of clinical practice in dementia care in Australia is variable. The availability of high-quality services to support workforce training, diagnosis and ongoing care, advance care planning and support for families to provide care is inconsistent’. (Laver et al., 2016, p.1)

Community Cognition and Dementia Service

Clinical Education

Multidisciplinary Team

‘A multidisciplinary care team which specialises in providing services for people with dementia (involving a medical practitioner, nurse and allied health staff) is best placed to provide a comprehensive assessment and treatment plan’.

(NHMRC Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People, 2016, p.12)

Client & family/carers

Geriatrician

Neuro

psychologist

Speech Pathologist

Dietitian

Occupational Therapist

Clinical Nurse

Consultant

Social Worker

Physio

Multidisciplinary Team

Diagnosis & Ongoing Management

‘Memory assessment specialists and services should offer a responsive service to aid timely diagnosis and should be able to organise a full range of assessment, diagnostic, therapeutic and rehabilitation services to accommodate the needs of people with different types and severities of dementia as well as the needs of their carer(s) and families living in the community’.

(Guideline Adaptation Committee, 2016, p.9)

Diagnosis

Diagnosis by geriatrician +/- neuropsychologist

Systematic approach to diagnosis

Experience with rarer forms of dementia

Management of waiting list

Established time frames for review

Ongoing Management

Management of symptoms & comorbidities

Monitoring of progression

Home visiting & care facility in-reach

Key liaison person

Care planning

Internal & external links

Carer & Family Support

‘Carer(s) and family should be supported to care for the person with dementia. They should be offered education and training to enable them to develop skills in managing the symptoms of dementia and be offered respite when needed. Carer(s) and family should be given information about coping strategies to maintain their own wellbeing and be supported to maintain their overall health and fitness’.

(Guideline Adaptation Committee, 2016, p.4)

Carer & Family Support

Monthly free ‘Starting the Conversation’ nights

Supportive counselling & education

Service navigation

Involvement in care planning

Joint feedback sessions

Clinical Education

‘Doctors, nurses, allied health and care workers should receive training in dementia care. They should be trained in how to communicate clearly with the person with dementia, their carer(s) and family and to provide person-centred care’.

(Guideline Adaptation Committee, 2016, p.4)

Clinical Education

Health promotion in local community

Behaviour management & support

Dementia friendly communication

Assessment tools

Service navigation

Research updates

Early Outcomes

25%

30%

30%

10% 5%

Referral Source

Cabrini

Consultant

Family

General Practitioner

Self referral

11%

4%

6%

41%

17%

6%

15%

Service Provision

Occup. Therapy

Nursing

Dietetics

Geriatrician

Neuropsychology

Social Work

Clinical Education

Quotes That Matter

‘I wish this service had been around earlier in my dad’s illness’ Family carer

‘We needed this service 10 years ago’ Local GP

‘I have seen five specialists over the past four years who thought I was just anxious. You are the first to tell me it is a disease’. Patient with PPA

Contact

lukesmith@cabrini.com.au

0437 139 313

References Guideline Adaptation Committee. (2016). Clinical Practice Guidelines and Principles of Care for People with Dementia. Retrieved from http://sydney.edu.au/medicine/cdpc/documents/ resources/CDPC-Dementia-Recommendations_WEB.pdf

Laver, K., Cumming, R. G., Dyer, S. M., Agar, M. R., Anstey, K. J., Beattie, E., ... & Dietz, M. (2016). Clinical practice guidelines for dementia in Australia. Med J Aust, 204(5), 191-93.

NHMRC Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People. (2016) Diagnosis, treatment and care for people with dementia: A consumer companion guide to the Clinical Practice Guidelines and Principles of Care for People with Dementia. Retrieved from http://sydney.edu.au/medicine/cdpc/documents/resources/consumer-companion-guide.pdf