To ensure people living with dementia and their carers get the right health and social care, at the right time, and in the right setting.

The World Health Organisation publication, continuity and coordination of care, reports that care co-ordination can improve patient and carer experience and outcomes, reduce hospital admissions and emergency department attendances and reduce lower medical costs.

Our key work in this area is listed below.

Improving care co-ordination for people with dementia in Inverclyde report

We are pleased to share the improving care co-ordination for people with dementia in Inverclyde report. The report was produced following an independent external evaluation of the work conducted by RSM UK Consulting LLP on behalf of the Scottish Government and provides an overview of our care co-ordination in the community improvement programme which concluded in March 2022.

Healthcare Improvement Scotland also produced an overview report outlining the key findings and our role in the programme. 

New dementia care co-ordination change package

We are pleased to share our latest dementia care co-ordination change package. The aim of this change package is to support community dementia services to improve the quality of PDS and integrated care co-ordination for people living with dementia and carers across Health and Social Care Partnerships in Scotland.

The change package which includes a driver diagram, change ideas, measures, and links to supporting evidence and resources.

My New Home - Supporting people with an intellectual/learning disability and advancing dementia moving into a care home 

People living with a learning disability are at increased risk of dementia when compared with the wider population. People with a learning disability and advancing dementia may move into a care home because their needs have increased and can no longer be met in their own home. 

To support their move, Healthcare Improvement Scotland and the Care Inspectorate, in collaboration with key partners, have developed guidance with an aim to enhance the appropriate care and support of people before, during and after a move to a care home.

Care Co-ordination Whole System Implementation

The Focus on Dementia team worked collaboratively with Inverclyde Health and Social Care Partnership from June 2019 until March 2022, to support the redesign of their dementia pathways from diagnosis to end of life, and to share learning across Scotland.

To find out more visit the Inverclyde Care Co-ordination web page. 

Care co-ordination for people with dementia in the community: The critical success factors

Working in partnership with Alzheimer Scotland, we commissioned an inquiry to explore and understand Midlothian Health and Social Care Partnership's approach to care co-ordination in the community for people with dementia and their carers. Twelve critical success factors to delivering successful care co-ordination support have been extrapolated from this work. 

The animation below explains what they are and how you can use them in your own service or organisation. 

Care co-ordination critical success factors self assessment form

The draft critical success factors self assessment form is available for you to complete. We would welcome any feedback on whether you have found it useful and if it has led to any service improvements. 

Alzheimer Europe Conference

We were delighted to present, a co-ordinated approach to post-diagnostic support: the critical success factors, alongside Alzheimer Scotland, at the virtual Alzheimer Europe Conference on 30 November 2021. 

Frailty and dementia evidence summary

The Evidence and Evaluation for Improvement team at Healthcare Improvement Scotland have produced a frailty and dementia evidence summary to inform the usefulness of frailty assessment tools in the management and co-ordination of dementia care. 

International Forum on Quality and Safety in Healthcare Europe 

We were delighted to share our e-poster, care co-ordination in the community for people living with dementia: an appreciative inquiry and data analysis to understand the critical success factors, at the virtual International Forum on Quality and Safety in Healthcare Europe, 9-11 June 2021.

Care co-ordination online workshop 

Through presentations and interactive discussion the Focus on Dementia Team hosted a webinar, on 27 October 2020, for colleagues to learn about care co-ordination for people living with dementia, including:

To find out more you can listen to the webinar recording or read our flash report summary

Evaluation of the effectiveness of the “8 Pillars” model of home-based support

The Scottish Government commissioned Blake Stevenson Ltd to undertake an evaluation of the 8 Pillars home-based support model for people with dementia, please click on the links below for more information and to download this report: 

How can I get involved? 

Follow us on Twitter @FocusonDementia 

For the latest news and updates from Focus on Dementia, including Care Co-ordination in the Community, please email us to be added to our mailing list. 

To ensure everyone can benefit regardless of their characteristics or where they access care, we completed an equality impact assessment. This highlights key equality issues that were considered by our project team, and any actions we took in relation to them. 

Contact us

Want to get in touch? You can email us

his.focusondementia@nhs.scot