Care co-ordination in the community for people with dementia in Midlothian  

Summary of an appreciative inquiry and data analysis to understand the critical success factors

Available evidence suggests that effective care co-ordination can lead to positive outcomes, including fewer hospital admissions and lower medical costs for people with dementia.

As part of the 2017 National Dementia Strategy in Scotland, there is a commitment to deliver a more flexible, co-ordinated and person-centred approach to supporting people with dementia in the community from diagnosis to end of life.

Our Focus on Dementia Team, working in partnership with Alzheimer Scotland, commissioned an inquiry to explore and understand Midlothian Health and Social Care Partnership's (HSCPs) approach to care co-ordination in the community for people with dementia and their carers. Data had shown that the overall resource costs for people with dementia in Midlothian are significantly lower than in other HSCPs in the NHS Lothian area, and people with dementia in Midlothian are significantly less likely to die in hospital compared to those in other Lothian areas.

Twelve critical success factors 

Twelve critical success factors to delivering successful care co-ordination support to people with dementia have been extrapolated from this work.

Currently many of these success factors will be in evidence across other partnerships in Scotland.

The findings from this inquiry – including the success factors – will help inform further development in dementia services in Scotland.

The inquiry was undertaken prior to COVID-19. Although services across Scotland may have had to adapt during the pandemic, the learning from this work will continue to be relevant and the critical success factors will be key in future service redesign.