Advanced Dementia Service - Bexley and Greenwich

• 1st set up in Greenwich in 2005• Expanded to Bexley 2012• Aim to work with people with

advanced dementia living at home

Why it’s needed

• People with advanced dementia often have complex physical and mental health needs

• Historically health services only get involved in a crisis

• Little advanced planning – despite knowing problems will occur

Unwanted outcomes

• Carers not sure who to refer to when changes happen

• Presentation at A&E / admission to hospital

• Admission to care home when not preferred option

Service in Bexley and Greenwich

• Oxleas funding part time CPN for a year

• Community Health Services provide community matron to work with CPN

• Dedicated psychiatrist time

• Caseload 25 people with advanced dementia living at home with carers

Service model

• Regular visits made by nurses

• Can arrange same day visit if needed in crisis

• Support to access equipment / other services

• Work closely with GPs

Kings Fund Research

• Project chosen by Kings Fund as demonstrator site for integrated working

• Outcomes to be presented summer 2013

• Aim to secure funding to continue to project

• Meeting soon with Bromley Healthcare

Kings Fund Model of Care

Analysis from Greenwich

• Worked with over 100 people

• 75% admission avoidance

• Average time on caseload 483 days

• Supported carers to talk through end of life planning

• Positive feedback from carers – some set up charity (www.hopeforhome.org.uk)