Older people with social care needs and multiple long-term conditions

Establishing the role

A community old age psychiatrist from the Older Adults Community Mental Health Team in Oxleas NHS Trust started the Greenwich Advanced Dementia Service in 2005 in order to improve continuity and care planning for older people with advanced dementia (it became part of the Oxleas Advanced Dementia Service in 2012). Two problems had been identified: a lack of coordination between GPs and specialists in secondary care, and an inability to secure GP home visits for patients, leaving them without a care plan or guidance on what to do in a crisis. The care coordinator role was established to work with people with advanced dementia and their carers to prevent hospital or care home admission, navigating through the complex health and social care system as a person's needs change.

Roles and responsibilities

The care coordinator's job is to assess, review, plan and respond quickly to the changing needs of the person with advanced dementia. They also support family carers, assessing and addressing their needs, and sharing information and advice with them about dementia. Much of the job involves liaising with health and social care services, a task which would otherwise be done by the carer, adding to their stress.

The care coordinator oversees delivery of the care plan, conducting ongoing assessments and setting up regular home visits, liaising with services and attending case conferences. Any changes to medication or the status of the patient prompts a follow-up letter to inform the GP. If a crisis occurs, they will try to visit on the same day. Staff are flexible and can usually be contacted by phone outside normal working hours. In the event of a hospital admission, the care coordinator liaises with hospital staff. The care coordinator also offers bereavement support to the family after the death of the person with dementia.

The service model can be summarised as follows:

Requirements of the role

Most importantly, the care coordinator needs experience and knowledge in dementia care. They also need good communication skills and an ability to advocate for the person with dementia and their carer. The team currently employs a range of professionals in the role of care coordinators, including nurses, occupational therapists and consultant psychologists.

Allocating a care coordinator

The individual's needs are reviewed by the psychiatrist and a specialist nurse. A named care coordinator is then nominated based on the patient's prevailing needs – physical, mental or social.

Care network

Care coordinators liaise with a large number of health and social care services: community GPs, secondary care, day centres, continuing care, care agencies, carer services, acute care, occupational therapists, social workers, respite providers, out of hours services, physiotherapists, district nurses and palliative care. They also work closely with family carers, including extended family members.

Health and social care context

The catchment area is covered by 2 neighbouring local authorities, Greenwich and Bexley, and the service is funded by the Better Care Fund. In Greenwich, care coordination is led by a consultant old age psychiatrist based in the local mental health trust, working alongside specialist nurses called community matrons. In Bexley, the same psychiatrist works with a community mental health nurse and an advanced practice nurse. Referrals come from a range of health and social care services.

Making a difference

An audit of the service has shown that 70% of patients die at home, compared to figures for England and Wales of 6% for people with dementia in 2010 (Alzheimer's Society 2012b).

The following outcomes have also been achieved:

Financial benefits

A basic cost analysis was carried out in the first year of the service. The results showed a potential saving of £10,983 per person for each emergency hospital admission avoided.

An audit of patients cared for by the Greenwich Advanced Dementia Service in 2009 reviewed 23 patients who received palliative care at home. The findings estimated savings to local health and social care commissioners of £177,200 to £310,100 for these patients.

Learning points