Care Co-ordination in the Community

Aim: 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 report 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.

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

We have identified 12 critical success factors for effective care co-ordination for people living with dementia and their carers. The animation below explains what they are and how you can use them in your own service or organisation. 

Inverclyde Dementia Care Co-ordination Programme: 
Learning and innovations in Inverclyde during the first wave of the COVID-19 pandemic

Inverclyde is the Dementia Care Co-ordination Programme implementation site, aiming to improve care co-ordination for people with dementia and their carers.

This case study shares experience from the Inverclyde Health and Social Care Partnership (HSCP) during the COVID-19 pandemic. Although not related to the Dementia Care Co-ordination Programme, it captures learning and innovations within Inverclyde HSCP that many other areas across Scotland may find of interest.

You can read the case study here.

Frailty and dementia evidence summary

The Evidence and Evaluation for Improvement team (EEvIT) at Healthcare Improvement Scotland were requested by the Focus on Dementia programme to rapidly review the evidence on frailty and dementia that would inform the usefulness of frailty assessment tools in the management and coordination of dementia care. 

You can read the full evidence summary and findings here

Care co-ordination workshop via MS Teams 
Tuesday 27 October, 14:00 - 16:00

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

  • A summary of evidence related to care co-ordination
  • A summary of the Midlothian HSCP experience
  • The 12 critical success factors

To listen to the recording please click here
To view the flash report please click here

Identifying critical success factors for integrated care co-ordination of people with dementia in the community: A focus on Midlothian

We have worked with Midlothian Health and Social Care Partnership to understand critical success factors in supporting care co-ordination for people with dementia and carers in the community. 

A report of findings published in September 2020 supports the spread of learning to other areas. To view the Dementia Care Co-ordination Critical Success Factors please click here

Care Co-ordination Whole System Implementation

The Focus on Dementia team will be working collaboratively with Inverclyde Health and Social Care Partnership over a 2 year period to support the redesign of their dementia pathways from diagnosis to end of life, and to share learning across Scotland.

To view our announcement visit our webpage.   

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

The Scottish Government commissioned Blake Stevenson 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: