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 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 webpage. To view the announcement about the collaboration visit the ihub news webpage

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

We 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. 

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 coordination 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 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.  

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 the Focus on Dementia team,  including updates on Care Co-ordination in the Community, please subscribe to our newsletter.

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. We are keeping this EQIA under review as the project progresses and we may update it if we receive new information.

Contact us

Want to get in touch? You can email us

his.focusondementia@nhs.scot