This project aims to improve care and support to people living with dementia and their carers in Gloucestershire in order to prevent unnecessary hospital admission and premature residential care admission as well as to reduce length of stay after a hospital admission.

The project involves:

• Anticipating support needed by carers (paid and unpaid) with enhanced training to help carers so that they are better equipped to deal with aggression, incontinence and insomnia for instance. These are some of the key factors triggering admission into care.
• Providing better responsive support to people living with dementia and their carers with an enhanced multi-agency team available 2417 to provide extra support over a short period (hospital discharge, crisis, etc).

Anticipated outcomes

• A reduction in inappropriate hospital admissions during a crisis when intensive medical and social support at home would be preferable and lead to better outcomes.
• A reduction in length of stay for people with dementia by return to existing level of care after a hospital admission.

The evidence base indicates that this will lead to:

• People living with dementia are able to return home when possible, as soon as possible – Reduced length of stay in hospital
• People living with dementia are able to remain at home as long as possible – Avoiding unnecessary hospital admission and / or premature admission to long-term residential care
• Avoid breakdown of care arrangements
• Improved quality of life for people living with dementia and their carers families
• Carers have access to training and support in time of crisis and after hospital discharge

Outcome metrics

• 200 carers and care workers up-skilled to better manage dealing with aggression, incontinence and insomnia (these are some of the key factors triggering admission into care).
• 250 carers and care workers feeling more confident, better equipped and better supported.
• 200 people living with dementia and their carers supported by the expert dedicated multi-agency short term intensive support team (available 24/7 to support carers in crisis or at a time of difficulties and helping with a return from hospital)
• 100 people living with dementia have avoided unnecessary hospital admissions or premature admission to residential care
• 100 people with dementia admitted to hospital have experience a timely return to existing level of care
• Average length of stay reduced by 2 days (LOS currently recorded as 9 days)
• 300 person living with dementia and carers report that their quality of life has improved

Progress update

• Enhanced reablement has started in 2 pilot areas and will expand to cover the county in the future.
• Resource kit developed to support Enhanced Reablement
• 2 community nurse workshops attended by 48 people.
• Carers DVD and workbook promoting engagement in development
• Refresh Primary Care Dementia pathway to place Memory Assessment Service nurses in primary care (Workshop in September)