What was the issue that required change?
An analysis of caseload activity and intervention for those with dementia within North Ayrshire appeared intermittent, ad-hoc and reactive. There is a need for proactive integrated health and social care pathways of care for over 65s and their carers living with dementia. A named community nurse would provide equitable access to support, information and care from diagnosis throughout all stages of illness to end of life.
How did you tackle it?
District Nursing teams co-ordinated a pathway of support for the individual and their carer, initiated at diagnosis of dementia.
What was the outcome?
A district nurse offered individuals with dementia and their carers’ access to advice from a hub of multidisciplinary professionals. This lead person allowed the team to work with the individual to develop a care plan focussed on outcomes to improve the quality of life for all involved. The service offered many opportunities to remain connected to the community. Additionally, applying a proactive caseload management approach reduced the requirement for unscheduled visits.