This document discusses efforts to improve post-diagnostic support (PDS) for people with dementia in Scotland. It describes 5 pillars that are being used to guide improvements to PDS, including establishing PDS leads and networks, capturing the impact of PDS through evaluation, developing a quality improvement framework, and relocating PDS services into primary care settings. Specific projects underway include testing a quality improvement framework with various sites, and shifting delivery of PDS from mental health teams to general practitioner practices in 3 locations. The benefits of relocating PDS to primary care are being explored. Overall, the document outlines initiatives to enhance and transform PDS for people with dementia in Scotland.

1. Connecting people, connecting support
Michelle Miller & Julie Miller
Focus on Dementia
ihub (Healthcare Improvement Scotland)
Elaine Hunter, Julia Mackenzie & Alison McKean
Alzheimer Scotland

3. Diagnosis
and Post
Diagnostic
Support
Integrated
Care Co-
ordination
Advanced
Care
Primary Care, Community,
Acute Hospitals, Specialist Dementia Units

4. Clip from national event
10 May 2017

5. Post-diagnostic Support
Julie Miller, Associate Improvement Advisor
Julie.miller20@nhs.net

6. 5 Pillars Model

7. Focus on Dementia supporting improvements to PDS
5 specific things we are doing (in partnership with
others)…..
PDS Leads group
PDS Network
Capturing the impact of post-diagnostic support
Developing a Quality Improvement Framework
Relocating PDS into 3 GP clusters.

8. PDS Leads & PDS Network
• Leads meet quarterly
• PDS Network launched in
November 2017
• Community of practice established
on the NES Managed Knowledge
Network - starting
conversations/sharing resources
• Newsletter (PDS Network News)
• Hot Topics – Technology &
Personal Planning
• Playlist for Life - bespoke session
for PDS practitioners.

9. Capturing the impact of PDS
An improvement project
With Post-diagnostic Support Link Workers,
Glenkirk Centre, Glasgow North West

10. Quality criteria in draft Quality Improvement Framework
The practitioner delivering PDS:
‘actively seeks feedback from me (and my carer) on the difference
PDS has made and how the service could be even better’
Glenkirk team:
1. Time to focus and reflect on how they capture the impact
2. Existing evaluation tool not being used, needed adjustment
3. Adjusted through a series of tests (PDSA cycles).

11. Effectively capturing?
*Can confidently evidence the difference PDS has made

12. Before and after……

13. Personal outcomes
It made such a
difference knowing
that someone
understood
It was really good to
talk openly about
dementia- I felt it
was good to be able
to “ face the
diagnosis”We feel more
confident
about the
future
I feel less
angry
I always felt
listened to
I feel less
frustrated and
irritable
What difference
has PDS made to
you?
I feel calmer

14. Delivering High Quality Post Diagnostic Support
The Link Worker Role
Julia Mackenzie
PDS Link Worker

15. Choice
Power
Control
Inclusion
Citizenship
Creative
Empowering
Building assets
Building strengths
Essential Elements For High Quality PDS

16. A Quality Improvement
Framework for Post-diagnostic
Support

17. The Framework so far…..
Draft 3
Aims to:
Improve the quality and experience of PDS for people with dementia, their
family and carers
Improve the experience of staff by ensuring they feel skilled, effective and
supported in their role
Be used as a motivator for improvement through self-assessment (Improvement
Plan template).

18. Shaped by personal outcomes
 I am confident in the people who support me
following my diagnosis
 I experience high quality post-diagnostic
support at the right time and at the right level
for me
 I know more about my dementia and have
adjusted to my diagnosis
 I feel listened to and what matters to me is at
the heart of decisions about me
 I feel better about the future knowing I have
made plans.

19. Structured approach to testing
3 cycles of testing between now and end September with 8 sites:
Cycles 1 & 2 -
Is it fit for purpose?
Do you understand all of the quality criteria? Are they realistic?
Would you be able to evidence that you meet these?
Is it easy to record information on the template sections?
Are there any revisions you would make?
Cycle 3 –
Testing for compliance against the quality criteria.

20. Relocating Post-diagnostic
Support into Primary Care

21. Background
• Scottish Government commission to Focus on
Dementia
• Shifting the delivery of PDS from Community
Mental Health Teams into GP Practices
• Capturing and sharing the benefits.

22. GP cluster work to date
Held open application process
Interim Knowledge Exchange
10 GP Clusters applied
3* sites selected.
Planning phase - initial meetings:
Edinburgh 22 June
Nithsdale 27 June
Shetland 20, 21 July.

23. What do you think the benefits might be of relocating
PDS into Primary Care?
Have a chat to your neighbour…..
Jot down on a post-it
Share some thoughts with us
Put on flipcharts on way out.

24. Thank you
Julie.miller20@nhs.net

26. Connecting people,
connecting support
Transforming the allied health professions’
contribution to supporting people living
with dementia in Scotland, 2017–2020

27. Elaine
ehunter@alzscot.org
@elaineahpmh
Alison
alison.groat@nhs.net
@AliAHPDem
#AHPDementia #ConnectingPeople #Connecting Support
#DAW2017
What matters to YOU? #WMTY17

28. • Arts therapists (art, music, dance, drama)
• Dieticians
• Occupational Therapists
• Orthoptists
• Paramedics
• Podiatrists
• Prothetists & Orthotists
• Physiotherapists
• Radiographers (diagnostic & therapeutic
• Speech and language therapists
Allied Health Professionals
who what? where?

29. Alzheimer Scotland
Transforming the System : Improving Lives

30. Scotland’s National Dementia Strategies
“We will commission Alzheimer
Scotland to produce an evidence
based policy document outlining
the contributions of AHP’s to
ensuring implementation of the 8-
Pillar model”
Connecting people, connecting
support 2017

31. Evidence for action
www.alzscot.org/ahp

32. Enhancing Daily Living Valuing everyday activities
Enhancing vocational & educational opportunities
AHP-led rehabilitation interventions
Adapting everyday
environments
Integrating environmental changes
Using everyday technology
Equipment adaptions to the home
Maximising psychological
wellbeing
Maintain & maximise communication
Psychological approaches
Psychological Therapies
Maximising physical wellbeing Keeping physically active
Falls reduction & fracture prevention
Eating well
Supporting families & carers Families as equal partners in care
Maximising your health and psychological wellbeing
Partnership working with health and social care
practitioners
Connecting people, connecting support

33. Connecting People, Connecting Support

34. Enhanced access
I am supported to look after my own health and wellbeing & do the
things that matter most to me
Partnership and integration
I feel I am treated as a person by the people doing the work, we
develop a relationship that helps us to work well together
Skilled AHP workforce
I feel I get the support and resources I need to do my job well
Innovation, improvement & research
The right care for me is delivered at the right time
How to make it happen : 4 ambitions

35. Enhanced Access
1. AWARE of what we do
2. SHARE what we do
3. IMPLEMENT home
based rehabilitation for the
dementia

36. Home Based Memory Rehabilitation Programme
Aim:
• Improve the care and experience of people with
dementia and their carers by December 2017,
• Develop & share a Model for National roll out of AHP
Best Practice by December 2017
Change Ideas:
• Promotion of programme in 12 areas based on
Dumfries & Galloway evidence
• Identified Leads in 12 Areas
• Establish National Communication networks
Enhanced access #OTHBMR

37. https://www.youtube.com/watch?v=qaHh3w4CR8I
What are your hopes for the future?
“we have turned a corner……we’ve started
getting away for wee breaks and that in itself is
a great benefit”
Improvement in practice
#OTHBMR

38. 1. Seek to understand
2. Power of relationships
3. Start small,
then make it smaller,
then make it smaller again!
Improvement in Practice
#ConnectingPeople our 6 tops tips
“The biggest
communication
problem is we do not
listen to understand.
We listen to reply” Covey

39. 4. The importance of measurement
5. Prepare to fail
6. Patience!
Improvement in Practice
#ConnectingPeople our 6 tops tips
“Without data, you are
just another person with
an opinion” Deming

40. “Connecting People, Connecting Support”
Transforming the allied health professionals’ contribution to
supporting people living with dementia in Scotland 2017-2020