This project will support dementia Link nurses in West Kent to work in primary care and proactively identify, diagnose, triage and assess people with dementia and provide appropriate prescribing and post diagnostic support.

There is an under diagnosis of dementia in West Kent and the dementia Link nurses will support increased prevalence rates of dementia. The Link nurse will liaise with the GP to undertake essential bloodtests, ECGs and imaging to ensure people with dementia are appropriately diagnosed and supported to manage their condition.

The vision for people with dementia in Kent is that people with dementia receive timely diagnosis and support that promotes their independence and helps them ‘live well’ with dementia, and that all services and support are provided to the highest possible standards: promoting dignity, choice and respect. The dementia Link nurses will support people with Dementia to be supported and managed in the right time, in the right place and by the right person.

In addition many of these people are treated in the acute setting and not primary care. dementia Link nurses will provide continued support in primary care and monitor patients in the community rather than the patient attending the acute trust. This will enable people with dementia to live independently through accessing support within community and primary care services rather than accessing acute services which unfamiliar environment may increase their confusion and disorientation and may result in crisis for the person requiring further acute input

Following assessments of people with dementia there will be discussions at multi-disciplinary meetings and a personalized care plan for these people will be agreed, implemented and reviewed. This will include end of life care; identifying early warning signs of deterioration; undertaking post crisis reviews and undertaking carer reviews. The MDM will also support the provision of education and support of the Health and Social care professionals who are responsible for these patients.

Objectives

• Improve education and understanding and there will be recognition of the difference between dementia and delirium
• Establish  agreed protocols of who makes the diagnosis and when
• Establish a diagnostic pathway with  an agreed timely process for assessment and review
• Ensure all people with dementia and their carers receive post diagnostic support and information. This includes:
  • Psychological support
  • Advance and end of life care planning
  • Information on support services
  • A carers assessment to identify their personal need while maintaining their caring role
• An increase in GP Dementia registers and a system to generate regular reviews
• Develop a skilled workforce within Primary Care to identify, diagnose and manage dementia safely at a practice level.
• Improve the ability of this patient group to remain at home for as long as possible
• Develop a greater understanding of dementia within multi-disciplinary teams with a specific focus on end of life care planning.

Anticipated outcomes

• All people with dementia will have access to a pathway of care that delivers a rapid and competent specialist assessment.
• People with Alzheimer’s disease benefit from early initiation of cholinesterase inhibitors where appropriate to delay the disease progression.
• People with dementia and their carers are supported and  able to continue doing the things they enjoy for as long as possible through improved and targeted management of dementia care
• People with dementia and their families across Kent & Medway are able to make decisions and plan for their future.
• They make an informed decision and have an advance care plan so that there ends of life wishes are respected.
• Carers are well informed about dementia and the progression of the condition and have access to local support groups and services to enable individuals to share worries and develop coping strategies with support from health professionals.
• All people with dementia receive an early diagnosis that enables them to make informed choices.
• People with dementia and their carers are confident of the care and diagnosis received in the new primary care memory pathway.