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Working with health and social care partnerships to improve post-diagnostic support and care co-ordination for people living with dementia and carers in the community

The programme aims to spread good practice to improve post-diagnostic support (PDS) and care co-ordination for people living with dementia and carers in the community. It supports the redesign and continuous improvement of community-based services across Scotland to improve the experience, safety and care co-ordination for people with dementia from diagnosis to end of life care. The emphasis is on supporting people to stay well at home or in a homely setting for as long as possible.

This programme will build on the combined learning from the PDS and Care Co-ordination improvement programmes:

  • Models of support including PDS, 8-Pillars model and Advanced Dementia Practice.
  • Care Co-ordination in the community for people with dementia in Midlothian. 
  • Testing the 12 Critical Success Factors for Care Co-ordination.
  • Inverclyde Dementia Care Co-ordination Improvement Programme. 
  • The PDS in Primary Care Programme.
  • General improvement work for PDS.

 

Support for health and social care partnership dementia services

We will support health and social care partnership (HSCP) dementia services by:

  • Developing a change package, clearly identifying the high impact changes from the learning from phase one.
  • Developing an evaluation framework and measurement plan to measure overall impact and outcomes. This will include qualitative data from people with lived experience.
  • Developing a measurement plan for each site to enable services to assess whether the changes they are making are leading to improvement. This will also enable meaningful comparative benchmarking across Scotland to help identify areas of good practice which could inform the ongoing evolution of the change package.
  • Providing support to participating HSCP teams to undertake a diagnostic to understand the effectiveness of their dementia pathway and identify the high impact priorities for improvement.
  • Building capacity and capability for improvement.

 

Joining criteria

We are currently inviting HSCPs to apply to join this 18 month programme. Teams are asked to meet the following criteria to ensure they have the conditions for change to successfully deliver sustainable improvements to dementia PDS and care co-ordination. These include:

Criteria 1: Organisational support from the HSCP to join the collaborative and confirmation of the Chief Officer as executive sponsor and a local implementation lead.

Criteria 2: Team members have time to participate in the national collaborative activities and deliver the local improvement project.

Criteria 3: Information on experience of/plans to engage with people with dementia and carers in Quality Improvement (QI) work and how this engagement will continue within this programme.

Criteria 4: Confirmation of the person who will help with local data analytical support.

Recruitment is open until noon on Monday 12 September 2022.

Visit join the programme for more information about the joining criteria, key dates, selection process and download the application form to join the programme.

 

Get involved

We are currently inviting HSCPs to apply to join this 18 month programme. We will select up to 12 sites to participate. HSCPs outwith the programme can still get involved by:

 

Get in touch

Email us at his.focusondementia@nhs.scot if you have a question about the Dementia Care Co-ordination Improvement Programme or if would like to speak to a member of the team about dementia PDS and care co-ordination in Scotland.