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Post-Diagnostic Support and Dementia Pathways

Explore the 5 Pillars Model for post-diagnostic support in dementia care, addressing challenges, gaps, and improvements. Focus on integrated pathways, named worker roles, and multi-disciplinary networks to enhance patient care and support from diagnosis onwards.

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Post-Diagnostic Support and Dementia Pathways

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  1. Post-Diagnostic Support and Dementia Pathways Pathways and Post Diagnostic Support Dementia Task Group

  2. Post Diagnostic Support – 5 Pillars Model

  3. 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?

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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)

  9. What do you think? • Who else needs to be involved? • How do we take this forward?

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