The CALHN Memory Service provides a single integrated specialist memory service across the Central Adelaide Local Health Network. It has an interdisciplinary team that provides flexible age criteria assessment, diagnosis, care planning and support for people with cognitive concerns. The model of care aims for early diagnosis and intervention, as well as consumer-directed care and culturally safe care for vulnerable populations. It uses a systematic approach including patient history, cognitive assessment, medications review and brain imaging to diagnose conditions like mild cognitive impairment and dementia. Key performance indicators help evaluate the effectiveness and timeliness of the service. Prevention strategies aim to increase brain reserve and slow cognitive and functional decline through education, social engagement, exercise, diet and treating health risk factors.

1. CALHN MEMORY SERVICE
Judy Deimel
Nurse Practitioner

2. SA Health
Content
• CALHN Memory Service (CMS) model
of care
• CMS approach to dementia diagnosis
• Case study

3. SA Health
Model of care
• Currently in Australia around 244 persons are
diagnosed with dementia each day.
• Some 25,938 persons are estimated to be living with
younger onset dementia in Australia in 2017(IGPA,
University of Canberra 2017).
• Various referral options for specialist diagnosis:
 Memory clinics, geriatrician, neurologist or
psychiatrist.
• CMS offers flexible age criteria, not limited to
65 years and over.
• Single integrated specialist memory service
across CALHN.
 Developed by CALHN Memory Service Working
Group.

4. SA Health
Central Adelaide
Local Health
Network

5. SA Health
Model of Care
• Clinical governance:
 Interdisciplinary team - specialist medical,
neuropsychology, nursing and administration
professionals (watch this space for ‘allied health’).
 Reporting to single clinical director - accountability
for patient safety, monitoring and improving the
quality of clinical care.
 Site: Ambulatory clinic at TQEH Main Bldg. Ward
5C.
> Coming soon – Ambulatory clinic at St Morris.
 Maintaining strong links with GP’s, Dementia
Australia and community service providers.
NHMRC Partnership Centre for
Dealing with Cognitive and Related
Functional Decline in Older People
2016

6. SA Health
Model of Care
• Aim for cognitive symptoms explored, when
first raised by the person with symptoms
and/or carer/family/GP.
• CMS core business: diagnostics, clinical,
social, preventative, educative and care
planning.
 Aim to promote health and wellbeing of people
with cognitive concerns.
 Aim to delay cognitive and functional decline.
• Enhanced communication between CMS,
consumer and GP verbal and written
feedback.
• Service delivery face to face; telephone,
telehealth / videoconferencing.

7. SA Health
Model of Care deliverable aims
• Aim 1: Early diagnosis and
intervention for people with
mild to moderate cognitive
impairment.
• Aim 2: Consumer directed
care for people with dementia
and their family and carer’s:
 Consumer engagement
throughout treatment and
management plan.
 Individualised and tailored plan
of care.

8. SA Health
Model of care aims
• Aim 3. Vulnerable population.
• One in five individuals with dementia are
from a cultural and linguistically diverse
background.
• Aboriginal and Torres Strait Islanders have
3-5 times the risk of developing dementia
than non-Indigenous persons.
 Culturally safe care by culturally
competent staff, for indigenous and
culturally diverse persons.
 Access to interpreters when required.
 Use of culturally appropriate assessment
tools.

9. SA Health
Referral information
reviewed by Triage
Nurse & additional
info sourced if
required
Appointment
booked with
patient by phone,
client registered.
Receipt of referral
to triage no longer
than 48 hours
1st clinical contact
with Triage Nurse or
Multi D Team
Email/Letter/Fax
request from
GP/Inpatient
PTT/Other health
care providers for
screening
Diagnosis of MCI >
6-12 Monthly review
in Memory Clinic
NAD Discharge to GP
Triage Nurse
informs patient they
do not meet referral
criteria, referred
elsewhere & letter
sent to GP
Appointment
confirmed, consent
obtained & wriiten
information sent to
the patient by
admin officer
Diagnosis of
Dementia
treatment
plan/information
provided
Stabilise therapy
over next 6 months
Discharge back to
the community with
NP follow up
(frequency to be
determined at the
time of discharge)
1st Appointment
with NP/ Triage
Nurse based on POA
Criteria
CALHN MEMORY SERVICE PATIENT FLOW
KEY
Patient Assessment
Dementia Diagnosed
Mild Cognitive
Impairment
Process flow if required
Patient referred to
ED if delirium/acute
rapid
decline/immediate
safety concerns are
identified
Single Point of Entry
Specialist review and
investigations
CMS systematic approach for
diagnosis and care
 Patient and informant
history
 Cognitive assessment
 Medication review
 Blood tests and
computed tomography
or magnetic resonance
imaging of the brain
1st Appointment
with medical
specialist or NP
1st clinical contact
with triage Nurse
Practitioner (NP)
Abbreviations:
ED: Emergency Department
GP: General Practitioner
MCI: Mild Cognitive Impairment
NAD: No abnormality detected
NP: Nurse Practitioner
PTT: (Inpatient) Primary Treatment Team
Triage Nurse Practitioner
informs referring clinician
the patient does not meet
referral criteria, alternate
referral pathway offered
e.g. Geriatrics, psychiatry,
GP mental health plan,
Palliative Care.
NP Cognitive Care
Clinic
 Supporting patients
and families when
expression of needs
is communicated via
actions and behaviour
Diagnosis of
dementia sub-type
at feedback
meeting, written
management plan
provided
Discharge back to the
community. Advised if
there are any concerns
with memory changes to
phone CMS NP for
advise or potential
review appointment.

10. SA Health
Key Performance Indicators
• Effectiveness of service:
 Total number of new referrals:
 Total number of referrals given appointments.
 Total number of referrals sent to Geriatrics or
Psychiatry / Mental Health.
 Number of ‘Did Not Attend’ at initial
appointment.
 Time between referral being accepted and first
appointment.
 Dissemination of outcomes to patient and
family.
 Feedback from consumer, family and GP

11. SA Health
Prevention better than cure?

12. SA Health
Social
determinants
of dementia
• Dementia risk
increases in the
elderly, the frail,
women, and the
socioeconomically
and educationally
disadvantaged.
• Risk factors are
contributed across
the lifespan (Lancet
Commission 2017)

13. SA Health
Potential brain mechanisms
for preventive strategies in
dementia
Increase brain
cognitive reserve
Education
Cognitive
training
Preserve
hearing
Exercise
Healthy eating:
Mediterranean
diet
Reduce brain
inflammation
Non-steroidal anti-
inflammatories
Rich social
network
↓Depression
↓obesity
Stop smoking
↓Brain damage
(vascular, neurotoxic,
oxidative stress)
Treat diabetes,
hypertension, ↑
serum cholesterol
(Lancet
Commission
2017)

14. SA Health
Case study

15. SA Health
Questions?