The Atlas of Shared Learning

Case study

Introducing a Dementia Support Service

Leading change

Led by their team manager and working closely with the Project Lead, mental health nurses at Somerset Partnership NHS Foundation Trust set up a new community-based Intensive Dementia Support Service (IDSS). It has had a significant positive impact on patients, carers and colleagues – providing interventions at point of crisis in the person’s usual place of residency, with the aim of reducing admissions to an older person’s mental health ward.

Where to look

The service in East Somerset for people with dementia requiring intensive assessment, support and treatment had been an inpatient service. A review of admissions over the 2016-17 identified unwarranted variation in available services and that there were a significant number of patients for whom hospital admission could have been avoided if there had been support over 7 days a week in the community. Dementia services nationally have been reconfiguring services to best meet the individual’s needs locally and to reduce the unwarranted variation in hospital admissions.

What to change

It is known that changes in living circumstances can significantly increase confusion and distress for people with dementia. The Dementia Support Service aims to assess, treat and support people in their familiar home environment. However, unwarranted variation in the provision of services to these individuals needed addressing.

How to change

Following visits to similar services elsewhere, a new Intensive Dementia Support Service (IDSS) was set up to work in the community. It was established with experienced ward staff who had good knowledge and experience of dementia. The new team includes mental health nurses, support workers and doctors, occupational therapists and assistant practitioners.

The team provides a service from 08:00 until 20:00, seven days a week which enables the team to visit the individual’s usual place of residence up to three times a day if required, and facilitate visits at times that support the patient and carers. The team provides assessment of the individual, medication review, carer support and advice, supported by personalised care planning. In addition the team provides education and support to care givers, liaising with other professionals and agencies involved – truly integrated care, closer to home.

To support the changes, a small number of specialist beds are available when an inpatient assessment or admission is needed. The service is being reviewed as it evolves, in order to provide a service that meets the patient’s needs, with an intention to extend the service to cover all of Somerset.

Adding value

  • Better outcomes – Feedback has been positive from community mental health colleagues, care home staff and from patients and carers. Previously likely hospital admissions have been prevented and a small number of early discharges have been facilitated. Carers have also benefited from regular advice and support. Patient stories have been captured which tell how the IDSS has made observable differences, particularly noting the reduction in number of services needed and minimising the number of ‘moves’ a patient makes in their journey of care, streamlining their care.
  • Better experience – Patients and carers have reported an improved experience as a result of IDSS involvement, frequently citing the extended operating hours that enable visits at convenient times, and that people can stay in their usual place of residence. Staff have quickly adapted to their new roles and there has been a noticeable improvement in partnership working across the teams involved in providing care.
  • Better use of resources – Reducing hospital admissions is a more effective use of NHS resources. Referral processes have been streamlined. All staff now have mobile phones and laptops to use for work and to assist them to operate remotely and make timely, accurate records of visits and have had community return on investment (RIO) training.

Challenges and lessons learnt for implementation

  • While in some cases, individuals with dementia may need specialist inpatient care, this new service demonstrates that with successful and appropriate treatment being provided closer to home, the number of individuals needing such admission will be reduced. Part of the learning is to assess the individual’s need and use this to inform their care pathway.
  • For many staff, the ‘joy’ of caring has been enhanced by this change as they get to see the patients from a new perspective – in the place where they live. This has strengthened relationships and the personalisation of care.

Find out more

For more information contact:

Emma Norton

Team Manager