Herefordshire and Worcestershires Living Well with Dementia Strategy 2019 - 24 Presented by Jenny Dalloway Transformation and Delivery Lead for Mental Health Worcestershire CCGs 2 Strategy Development - the journey so far. Previous separate strategies for Herefordshire & Worcestershire Dementia Needs Assessment Engagement survey (over 90 responses) Workshops (over 80 people attended) Healthwatch engagement and feedback Carer Association Support Second workshop to support action prioritisation (over 50 people attended) Endorsed by STP and Health and Wellbeing Boards Included people with dementia, their carers, members of the public, volunteers, professionals and organisations involved in research, education and the care and support for people affected by dementia. Ensuring there have been no missed opportunities for feedback

3 Local Picture memory clinic referral went smoothly along with appointment was an overview of what to expect .. experience was good, ongoing support excellent we have a remarkable CDN Having support from a DA has reduced my anxiety and made me feel that I am not so dreadfully alone Thank you so much for all the help you have given over the years. We would have been lost without you. People really like the meeting centre as it runs for a good amount of time. For one gentleman, it gave his wife (carer) a break and he wishes there was more things like it where he could go on other days of the week. Person with LD and dementia I do like the signs and I want to put my photo on my bedroom door. Person attending a Memory Morning Drop In

It was a friendly setting where I was able to talk freely about my concerns without family members talking for me. 'As always your support and advice is very much appreciated. You are such a help for people like us as individuals, and for the community as a whole Family carer of person with LD There is a definite change where my learning disabled daughter lives. I observe the person who has learning disability and dementia now listening to music through headphones, and the environment is dementia friendly. The rugs and patterns are all gone; the carers have really embraced the learning. The impact on other people who have a learning disability who live there is that they are more relaxed. They have stopped telling her to be quiet. Local Picture - what could be better? Dont forget that those with a diagnosis of dementia may have other health issues , pathways must accommodate this as risk of overshadowing can occur without proper integration We need more dropsins. Lots of groups in the area but not enough coordination between them, for example, everything seems to happen at the same

time/day. You will need to train your workforce to attune to the needs of younger, physically fitter people being diagnosed with dementia. How will they wish to be supported by you? People will expect to stay active, working and engaged in their community We need to keep talking about dementia and all risk factors associated with it Knowledge is Power Support staff to develop knowledge skills and confidence in advanced care planning at an appropriate time for the person and their carer, and managing end of life when the time comes ( Carer) Professionals need to understand dementia can make people intolerant of waiting; noisy places but few have taken this on board Dementia can be a very lonely place, encourage open discussion and easier access to help available so that people are not scared of diagnosis and feel confident to make the necessary adjustments to live well Reach out to communities to address their negative attitudes towards living

next door to someone with dementia & how they can support them its not all about the staff/professionals. We all have a role to play in addressing stigma Hard to find affordable, short-term, ad hoc respite mother is settled at home and it would be better if someone could come to the home even if it was just for a few hours. Family member Dementia Strategy Key Messages Focus on prevention greater emphasis on primary prevention of dementia Continue to build dementia-friendly communities in collaboration with key partners in localities and neighbourhoods Identify passionate multi-agency leaders and champions who will work together to support delivery of this strategy within locality and neighbourhood teams Support the expansion of the Meeting Centre Model which nurtures community partnership to support access to user-led dementia friendly community facilities 6 Dementia Strategy Key Messages Endorse and support the Dementia Action Alliance movement to address stigma and fear and create dementia friendly communities & environments Recognise, appreciate and support carers enabling them to their role Build on identification and diagnosis including underrepresented groups Develop and implement Advanced Care Planning to inform palliative care needs and improve dementia

end of life care and support in the community Awareness; Information, Education, Training for All to achieve informed, caring and compassionate communities 7 Dementia Strategy Key Challenges Stigma and Fear about dementia Increasing demand due to aging population Complexity owing to co-morbidities Capacity pressures in home care and care home market Financial constraints across health and social care Third sector financial constraints Engagement with wider community and underrepresented communities Pressure for affordable respite care Maintaining high profile within wider Health and Social Care agenda The scale of the challenge is significant with an estimated 12,500 people currently living with dementia in Herefordshire and Worcestershire including 600 people with young onset dementia. 8 Dementia Friendly Herefordshire and Worcestershire The well-being and quality of life for every

person affected by dementia to be uppermost in the minds of all health and social care professionals Well Pathway Delivery Plans Preventing Well Diagnosing Well Supporting Well Living Well Dying Well Stakeholders have identified the top three priorities in each of the well pathway stages 10 Preventing Well High Level Actions Outcomes Priority 1 Develop pro-active dementia support model within Locality and Neighbourhood teams

Priority 2 Educate Communities (all ages) of the impact of physical and mental wellbeing on preventing dementia Awareness of Dementia and the link with Physical Health is aligned with 0-19 Services Development Strategy (CYP) and Integrated Care for Older People Programmes (ICOPE) strategies. Priority 3 Strengthen dementia risk reduction messages in NHS Health Checks and within public health & wellbeing opportunities /initiatives incl schools and workplaces Increased prevention opportunities offered as early as possible to people to minimise risks of developing dementia (schools/colleges initiatives) Raised dementia awareness leading to timely diagnosis Public Health take a lead role in the Dementia Partnership Programme Board Locality and neighbourhood teams have received dementia friends training and have access to tools and approaches to be pro-active in providing care and support to people affected by dementia.

Increased use of contingency & Advanced Care Planning in care plans ReSPECT Tool implemented to guide Advanced Care Planning process across professionals and teams Shared care pathway Increased update and use of assistive technology Dying Well 11 Diagnosing Well High Level Actions Outcomes Priority 1 Addressing equalities around accessing a dementia diagnosis and services is a key strand of our pathway work and fundamental to early diagnosis and support Work with partners to continue to ensure clearly signposted, robust culturally competent and locally informed services and post-diagnostic support pathways An engagement and empowerment approach adopted by all partners to reach and include BME, rural and unrepresented communities (those with a Learning Disability, farming and travelling communities) Increased awareness and understanding of signs and symptoms of dementia among all population groups Priority 2 Address local stigma and negative image of dementia which is creating fear and a sense of hopelessness within our aging population

Communities are empowered to champion the benefits of early diagnosis Neighbourhood/Locality support is available for people who are reluctant to be assessed and receive diagnosis All partnership members are dementia friends Communication and engagement strategy established to achieve consistent language used to describe dementia Local Media are partners in Dementia communication and engagement delivery Patients and carers participate in promoting positive messages about living with dementia Priority 3 Review local Pathways to include Mild Cognitive Impairment Dying Well Herefordshire and Worcestershire are dementia friendly counties with local supportive communities A recognised and fully supported pathway in place to identify, clinically code and review patients with an MCI. People with MCI and their carers have access to drop in sessions at locality/neighbourhood level which provide information and support about self-care and when to seek further help 12 Supporting Well High Level Actions

Priority 1 Workforce Development to ensure the principle of personalised dementia care is embedded and we achieve high levels of expertise throughout the dementia pathway Outcomes Increased training and support for informal carers to support them in their carers role and to facilitate improved health and wellbeing for carers Priority 2 Review and promote dementia information and support to ensure it includes prevention, diagnosis, living well, supporting well, and planning for end of life with appropriate signposting to local community support opportunities /groups Develop Information and advice resources to be made available for people attending peer support groups ( e.g. drops-ins; Meeting Centres) Priority 3 Strengthen leadership, accountability and recognition for delivery of the strategy

1. 2. 3. 4. Improved and increased education, training and opportunities for skills development for all (including informal carers) who are involved in the care and support for people affected by dementia Training opportunities are available and aligned to the different stages of dementia progression. Care Home and Domiciliary Care staff at all levels have access to specialist level dementia education to enhance knowledge, skills and competencies enabling them to deliver person centred care Dementia skills training is embedded within all contracts with Care Home and Domiciliary Care Providers Carers programme offering specific support for people caring for someone with dementia Assessment, management and support for people living with dementia and their carers is delivered in accordance with NICE Guidelines (NG97) Dying Well There is an established consistent approach to ensure everybody affected by dementia has timely access to information advice and support A single point of access (SPA) and road map signposts people to local dementia information, care and support Hospital and community services use standardised information packs for people who are newly diagnosed and carers packs for their family/friends Standardised welcome/Information packs are also issued at community support including cafes, drop ins and meeting centres Visible local media campaigns are part of an on-going programme of communication and engagement Dementia Partnership Programme Board includes clinical and executive level leadership and accountability from across the system Clinical and Organisational Leadership roles are well established, promoted and recognised across partners

An Annual Dementia Recognition Awards recognises contributions to the following: Communication Leadership and management Learning and Improvement Special Achievement 13 Living Well High Level Actions Outcomes Priority 1 Strengthen leadership and accountability for delivery of the strategy Dementia Partnership Programme Board includes clinical and executive level leadership and accountability from across the system Priority 2 Continue to build and extend dementia friendly communities through the contribution of community and partnership working An established protocol to support organisations to become dementia friendly There is greater awareness and involvement by the community in local drop-ins A Dementia Friendly Housing Charter and Toolkit in place with all housing partners Dementia friendly local environments (e.g. Hairdressers) to support people to remain connected to

their local community Schools/Colleges are participating in Dementia Friends training and intergenerational activities to promote dementia awareness and understanding A network of dementia friendly community pharmacists, podiatrist, dentists, opticians supporting people with dementia linking in with drop-ins to help with sign-posting and earlier recognition for diagnosis and support Reinforce the strategic direction of the Dementia Action Alliances to ensure a co-ordinated approach in delivery of priorities An increase in the number of organisations, businesses, Council departments and community groups signed up to the local Dementia Action Alliance working together to achieve dementia friendly status Priority 3 Work collaboratively to achieve a co-ordinated patient-centred pathway across partners Dying Well Patients and carers are partners in care planning Partners collaborate to achieve a seamless pathway which promotes and respects patient and carer choice and control A clear pathway and process exists enabling adaptations in the home and access to assistive technology to support independent living 14 Dying Well

High Level Actions Priority 1 Strengthen leadership, accountability and recognition for delivery of the strategy Outcomes 1. 2. 3. 4. Priority 2 Continue to develop integrated dementia palliative and end of life care delivered at locality and neighbourhood team level so that Dying Well is a seen as a crucial element of good dementia care Alignment with Frailty and End of Life programmes of education about a range of topics on recognising and supporting people in the advanced stages of dementia Develop a template in GP practice systems with items to include when undertaking a review for care home residents with dementia which includes palliative care categories Priority 3 Continue to create responsive community services which promote re-ablement and effectively manage

crises for people affected with dementia either at home or in a care home Dementia Partnership Programme Board includes clinical and executive level leadership and accountability from across the system Clinical and Organisational Leadership roles are well established, promoted and recognised across partners An Annual Dementia Recognition Awards recognises contributions to the following: Communication Leadership and management Learning and Improvement Special Achievement Dying Well A skilled multi-professional neighbourhood/locality team supported by dementia end of life specialist and care home liaison teams working together to identify, register and support people in the community and in care-homes who need palliative and end of life care. Local professionals feel confident using the ReSPECT Tool to support advanced care planning discussions & conversations about death and dying; encouraging people to complete living Wills and lasting powers of attorney so that personal end of life wishes are recorded and respected Carers/Families have access to GP services out of hours for support with crisis management (behavioural, psychological symptoms of dementia) Carers and families receive emotional support when the person they are caring for is in the last days of life and have access to bereavement support Neighbourhood and Locality teams have access to both hospital avoidance service (out-reach support) and specialist advice and support when managing a crisis Good quality, flexible home care services available to help dementia patients maintain independence and reduce social isolation A network of support for care homes facilitates advanced dementia care planning including palliative care and end of life care

15 Next Steps CCG is supporting partner organisations to feedback on the draft strategy to ensure alignment with relevant local strategies incl. Housing, ICOPe (Integrated Care for Older People) and Digital Technology. Dying Well Full Launch Planned Summer 2019 16 Any Questions? 17

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