The King’s Fund (funded by Aetna and the Aetna Foundation) is releasing a series of five case studies examining co-ordinated care for people with complex chronic conditions. New approaches to care co-ordination in primary care settings are investigated, across the UK. Each case study explores issues including the care planning / co-ordination process, patient stories and team-working approaches.
The latest co-ordinated care case study in this series is about the Oxleas Advanced Dementia Service, which provides patients with advanced dementia living at home with specialist palliative care and support.
“The provision of care at home for people with advanced dementia is fairly rare in England as most people in the advanced stages of the disease die in a care home or in hospital. The Oxleas service works with family and carers to prevent hospital or care home admission, navigating through the complex health and social care system as patients’ needs and their entitlements to support change”.
Read more: Oxleas Advanced Dementia Service. The Kings Fund.
Important aspects of this service include:
Carer Resilience: carers are central to the Oxleas model. Staff provide tailored care and advice to alleviate carer distress. The idea is to improve their quality of life and support their ability to care for the patient.
Case Finding and Relationship Building: suitable patients are identified through the roles of staff in mental health or community teams. Teams work across physical and mental health services.
Multiple Referrals to a Single Entry Point: referrals are accepted from a wide range of health care professionals. A standardised referral form is used to capture information, and there is a single system for assessing and allocating cases to care coordinators.
Holistic Care Assessments and Personalised Care Plans: a single comprehensive patient assessment and carer assessment addresses physical, mental health and social care needs. A personal care plan is used to put required services place, with an emergency plan to deal with crises. Care plans are reviewed and updated to reflect changing needs of patients and carers.
Care Co-ordination: the care co-ordinator is primary contact with the patient and family, liaising with other care providers to co-ordinate services and providing support for patients and their families. This is usually a specialist nurse with physical or mental health skills.
Multidisciplinary Team-Working: there is rapid access to advice and support, either from the care co-ordinator or a delegated member of the team.
Sonola, L. Thiel, V. Goodwin, N. [and] Kodner, D.L. (2013). Oxleas Advanced Dementia Service: supporting carers and building resilience. London: The King’s Fund, September 2013.
[A brief reference to this item features in Dementia: the Latest Evidence Newsletter, Volume 3 Issue 10, September 2013].