This case study, published by The King’s Fund, looks at how Oxleas Advanced Dementia Service provides care co-ordination, and specialist palliative care and support to patients with advanced dementia living at home.
The video below explores the co-ordinated care approach provided by Oxleas Advanced Dementia Service.
Key learning points
- Building resilience among carers
Carers are seen as a key a facet of the Oxleas model; staff provide tailored care and advice to alleviate carers’ stress and to improve their quality of life and ability to care for the patient.
- Case finding and relationship building
Staff identify suitable patients through their other roles in the mental health or community teams. A supportive culture surrounds all staff working within the service, and members of the team have built strong yet flexible links across physical and mental health services.
- Multiple referrals into a single entry point
Referrals are accepted from a wide range of health care professionals and a standardised referral form is used to capture information that flows into a single system for assessing and allocating cases to care co-ordinators.
- A holistic care assessment and a personalised care plan
A single comprehensive assessment of the patient and carer addresses physical, mental health and social care needs. Following the assessment, a personal care plan is produced to put in place the services required and an emergency plan is put in place to deal with times of crisis. Care plans are continuously reviewed and updated to reflect the progressive nature of the disease and the changing needs of patients and carers.
- Dedicated care co-ordination
The care co-ordinator takes on the role of primary contact with the patient and family, liaising with other care providers to co-ordinate services and providing emotional support for patients and their families through to death. This role is usually filled by a specialist nurse with physical or mental health skills.
- Rapid access to advice and support from a multidisciplinary team
The patient and carer are given a phone number for the care co-ordinator; if a crisis occurs or they need advice over the phone, the co-ordinator will respond or delegate to another member of the team.