Holistic care for people with dementia in South East Hampshire

ContactVictoria McDonald, NHS South East Hampshire CCG
Telephone02392 282061
AddressCommissioning House, Building 003, James Callaghan Drive, Fareham, Hampshire, PO17 6AR

This project will provide the capacity and expertise to maximise the effectiveness and extend the impact of the multi-disciplinary Community Care Teams in South East Hampshire.

Older people often have inter-related complex difficulties requiring support and interventions for physical and mental health, and social care needs. The aim of the Integrated Community Care Team is to address this wide-ranging need.

This project will ensure that mental health is fundamental to the delivery of integrated care in South Eastern Hampshire and to enable the coherent ‘joining-up’ of services to deliver comprehensive care.

The project will support the delivery of a number of the key priority areas for the Innovations Fund, namely:

  • Community based care
  • Improving diagnosis
  • End of life care
  • Reducing inappropriate antipsychotic prescribing, and
  • Carers.


The project will deliver:

  • Training and awareness raising about dementia skills for generic staff;
  • Early detection and diagnosis in the community, linking with memory services and the new Dementia Advisor service (starting in October 2012);
  • Reduce inappropriate use of antipsychotic medication by raising awareness about the risks of antipsychotic medication and alternative interventions;
  • End of life care, recognising the particular needs of people with dementia; and
  • Support for carers.

The Community Care Teams wiIl serve a population of 40,000 (over 65 years) and provide community based support for people with dementia and their carers living in the community. The Team’s main aim is to optimise the wellbeing of patients who have been assessed to be at risk of deteriorating physical and or mental health, or social decline, or a combination of all three. It does so by a case managed approach. This enables joined up care, with professionals working to each patient’s goal focused holistic care plan. This avoids duplication, whilst ensuring the relevant professionals are involved.

Anticipated outcomes

People with dementia will experience:

  • Services that are designed and delivered around their needs;
  • Increased personal choice and control; and
  • Care and support that is delivered with dignity and respect.

Specific outcomes for people with dementia and their carers will be:

  • support with earlier diagnosis through liaison with the Dementia Advisor and sign- posting to information and support;
  • improved health and wellbeing, only going into hospital when it is necessary, having as short a stay as possible and having regular reviews of their medication;
  • support to maintain their independence in the community, receiving reablement care to optimise their capabilities and resilience and support on discharge from hospital;
  • carers’ assessments and care plans, with sign-posting to information and support;
  • support with advanced care planning and care towards the end of life for both the person with dementia and their carers; and
  • speedy and timely access to specialist mental health care and support.

Staff in the Community Care Teams and other related services, for example the voluntary agencies providing meals on wheels, will gain core skills in dementia care.