Case Study Three: Dementia Reablement Service for Cheshire East An example of a how integrated care is working across Eastern Cheshire. Presented at the Caring Together stakeholder event at Poynton Civic Centre 20July 2015 www.caringtogether.info

1. Integrating Care in Eastern Cheshire
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2. What is the Dementia Reablement Service
• 12 month pilot
• Funded through the Better Care Fund
• Liverpool John Moores University are evaluating the
pilot
• Performance data and case studies to measure impact
• Action learning with the DRS teams & Customers
• The service will develop based on the input from Customers,
LJM and the Reablement Team

3. Why do we need to provide additional support?
• Identified that there was a clear gap in post diagnostic
support for individual and carers living with dementia
• 5,000+ people in Cheshire East living with Dementia
• The number of people aged 65 or over living with dementia in
Cheshire East is expected to rise by more than 40% by 2030

4. Identified outcomes for customers accessing the DRS
• To lead full and active lives
• Able to remain in their own home for longer
• Develop skills to manage the challenges of living with
dementia
• Increased confidence and self-esteem
• Reduced feeling of social isolation
• Improved emotional well-being
• Ensure Legal & financial arrangements in place

5. How will the service do this?
Provide a short-term personalised service to the
individual with dementia and their carer:
• Visit individual and carer, and get to know them
• identify what is concerning them in relation to their
dementia
• identify what people need help and support with in
relation to their dementia
• provide information on local dementia services and
dementia friendly activities
• provide a personalised action plan

6. Eligibility Criteria:
Individual must have a diagnosis and be in the early stages of
Dementia
Referral Route:
• Memory Clinics
• GPs
• Social Care teams
• Self referral

7. Improving Integration
1. The service has been jointly commissioned by health and social care
2. Close working with Memory Clinics to establish a simple, easy to manage referral
process- ensuring a timely and appropriate referral
3. GP buy in- the service has presented to GP and Nurse groups and will continue to
work with identified GP leads to ensure the service is accessed by all practices across
the Borough
4. Working closely with social care teams and the End of Life team to support people to
plan their support and care for the future, arranging additional care and support
where appropriate
5. The service is part of the wider dementia strategy designed to ‘join up’ support for
individuals and carers
6. Working closely with VCFS organisations such as AGE UK and The Alzheimer's Society

8. Improving the Journey for Customers and their Carers
1. Creation of a Service Reference Group to inform how the service is delivered in the
future
2. Service summary letter will be sent to the persons GP to inform the GP of the
individuals support plan, and the outcomes that person has achieved
3. The DRS team are using a shared care notes system with Memory Clinics, this will
ensure professionals are fully informed about an individuals case history
4. Due to the good working relationship with Age UK and Alzheimers, the service is
able to signpost customers to these services for ongoing support

9. What next
1. Continue to develop a single pathway following diagnosis will
support individuals and their carers to manage better and reduce
stress and confusion of multiple contacts with the health & social
care system
2. To identify any unmet need/ demand from individuals and carers
3. Further develop the service to ensure that the needs of people
using the service are at the centre of service planning