NHS North Somerset Dementia Pathway and Payment by Results

This illustrates care packages for people living with dementia across four care clusters in line with payment by results for mental health.

Download NHS North Somerset Dementia Pathway and Payment by Results

People with dementia will be assessed as being in any of the 21 care clusters, care clusters 18–21 are being focussed upon here as these clusters would be appropriate for people whose needs are primarily due to their dementia (people can receive any additional service they require not just those within the cluster they are in)

People will be reviewed using outcome measures and they will be re-clustered (may be to same cluster) and new care plan will be developed people may step down to a lower level of support or step up to a higher level of support

Care Cluster 18

Early to moderate, receiving a diagnosis and post diagnostic support

People may be in the early stages of dementia (or who may have an organic brain disorder affecting their cognitive function) and have some memory problems, or other low level cognitive impairment but are still managing to cope reasonably well. Underlying reversible physical causes have been ruled out.

Care Cluster 19

Post diagnostic support and ongoing support and management. Middle stage dementia

Cognitive Impairment complicated moderate need

People who have problems with their memory, and or other aspects of cognitive functioning resulting in moderate problems looking after themselves and maintaining social relationships. Probable risk of self neglect or harm to others and may be experiencing some anxiety or depression.

Care Cluster 20

Middle–late stage dementia. Cognitive Impairment complicated high need

People with dementia who are having significant problems in looking after themselves and whose behaviour may challenge their carers or services. They may have high levels of anxiety or depression, psychotic
symptoms or significant problems such as aggression or agitation. The may not be aware of their problems. They are likely to be at high risk of self-neglect or harm to, and there may be a significant risk of their care arrangements breaking down.

Care Cluster 21

Frailty due to dementia or physical health middle to late stage dementia & rarely early dementia. Cognitive Impairment (High Physical/Engagement)

Characterised by cognitive impairment or dementia, with significant problems looking after themselves and whose physical condition is becoming increasingly frail. There may be significant risk of care arrangements breaking down