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.

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. 

Care co-ordination critical success factors self assessment form

The draft critical success factors self assessment form is available here for you to complete. We would welcome any feedback, via email, using the address in the contact us section below, on whether you have found it useful and if it has led to any service improvements. 

Inverclyde Dementia Support and Services Leaflet

A priority area for the Inverclyde Dementia Care Co-ordination Programme is to improve information provision for people living with dementia and carers, at point of diagnosis. In response to this a leaflet was developed that contains information and contact details for health, social care and community services and supports in Inverclyde. This information is intended to support people living with dementia to manage their condition, to live well and independently at home and stay connected to their local community.

The leaflet was co-produced with our Programme stakeholders and the Inverclyde Dementia Reference Group. The Dementia Reference Group is for people living with dementia and their carers to share their stories, ideas, and experiences. They also help identify areas for improvement and arrangements are in place for the group to support and inform the Dementia Care Co-ordination Programme.

Information on dementia friendly Inverclyde can be found on the Inverclyde Council webpage. 

Community and Dementia: Creating Better Lives in Greater Glasgow and Clyde

The Life Changes Trust, in partnership with individuals and organisations from across Greater Glasgow and Clyde, held an online conference in August 2021 to reflected on what was happening locally to support people living with dementia and their families and where services and support needed to be improved. 

Brenda Friel, Inverclyde Health and Social Care Partnership gave an overview of our Care Co-ordination Programme and spoke with Doreen Borland, an unpaid carer who is part of the Reference Group for the programme. You can watch Brenda and Doreen's video here. The recording of the full webinar, as well as each standalone presentation, is available on the Life Changes Trust Community and Dementia: Creating Better Lives in Greater Glasgow and Clyde webpage

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.

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.

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 coordination of dementia care. 

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:

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

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

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 dementia care co-ordination 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. 

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 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: 

Contact us

Want to get in touch? You can email us

his.focusondementia@nhs.scot