Oxleas Advanced Dementia Service: Supporting carers and building resilience

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Part of Co-ordinated care for people with complex chronic conditions

This case study looks at Oxleas Advanced Dementia Service which provides care co-ordination, and specialist palliative care and support to patients with advanced dementia living at home.

This case study is part of a research project undertaken by The King’s Fund and funded by Aetna and the Aetna Foundation in the United States to compare five successful UK-based models of care co-ordination.

What does the service aim to do?

The service seeks to help patients with advanced dementia to live at home in the last year of life with support from family and/or carers.

How is the service structured?

In Greenwich, care co-ordination 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 psychiatric nurse, an advanced practice nurse and a social worker specialising in dementia. Staff in the service liaise with community mental health services and general practitioners to provide care in patients’ own homes, focusing on supporting the carer and/or family to provide palliative care for the patient.

View our organogram for more about the Oxleas Advanced Dementia Service care planning/co-ordination process

What is distinctive compared to the standard practice of care?

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.

What are the key lessons?

  • Building resilience among carers
    Carers are seen as a key a facet of the Oxleas model; staff provide tailored care and advice to alleviate carers’ stress and to improve their quality of life and ability to care for the patient.
  • Case finding and relationship building
    Staff identify suitable patients through their other roles in the mental health or community teams. A supportive culture surrounds all staff working within the service, and members of the team have built strong yet flexible links across physical and mental health services.
  • Multiple referrals into a single entry point
    Referrals are accepted from a wide range of health care professionals and a standardised referral form is used to capture information that flows into a single system for assessing and allocating cases to care co-ordinators.
  • A holistic care assessment and a personalised care plan
    A single comprehensive assessment of the patient and carer addresses physical, mental health and social care needs. Following the assessment, a personal care plan is produced to put in place the services required and an emergency plan is put in place to deal with times of crisis. Care plans are continuously reviewed and updated to reflect the progressive nature of the disease and the changing needs of patients and carers.
  • Dedicated care co-ordination
    The care co-ordinator takes on the role of primary contact with the patient and family, liaising with other care providers to co-ordinate services and providing emotional support for patients and their families through to death. This role is usually filled by a specialist nurse with physical or mental health skills.
  • Rapid access to advice and support from a multidisciplinary team
    The patient and carer are given a phone number for the care co-ordinator; if a crisis occurs or they need advice over the phone, the co-ordinator will respond or delegate to another member of the team.

More information about the service

For more information about Oxleas Advanced Dementia Service, please contact Estelle Frost, Director of Older People's Mental Health Services, on estelle.frost@oxleas.nhs.uk

Oxleas Advanced Dementia Service were winners of the 2013 NHS Innovation Challenge prize for dementia.

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Christina Hulse

Dementia lead,
Bham Community healthcare
Comment date
02 November 2014
I have just started a 6 month secondment as dementia lead. I have been reading some of your work and it is very impressive. I am trying to sort out a holistic care plan for dementia care. I understand these need to be individualised. This is to encourage staff to look at and understand the different daily requirements. I am also working on a 'this is me' type handbook. If possible I would like any information on care plans for inpatients or patients looked after at home. - thank you

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