Planning for the future Encourage Power of 95% of patients to have Attorney conversations, had a discussion about advanced care plans, wills. End of Life planning in Dementia; the future at their Consider early annual review conversations around EoL; Advanced Care Planning in Dementia preferred place of . care/death and DNR status principles Potential Ideas for Resources Outcomes Action Plan Planning for the Consider each patient with Consider regular meetings with a MDT to discuss patients on the Quarterly meetings with present Dementia at a register ( similar to Gold Standards Meeting) suggested attendees; GP, action plans and meeting. Practice Nurse, Dementia Champion, Local Carers support rep, District minutes /reports Nurse, Dementia Advisor/ CPN, social worker, pharmacist. Consider sharing a plan for 85% to have a shared each patient on the Shared Care Plan on platform Care Platform ( as used for To produce a Care Plan as required for the Avoiding Unplanned the Avoiding Admissions Admissions DES and publish on the shared care platform. DES) Appointment Flag patient notes with an 85% of patients to have management to offer a double notes “alert” “flagged” appointment if appropriate Encourage patients to a 100% of patients to carer/friend to appointment have named clinician ( To send patient GP or Nurse) as key prior to appointment co-ordinator If patient’s DNAs, to proactively rebook an appointment Post Diagnostic referring patients 95% patients made Consider Support Service aware of the local on to dementia ‘post Dementia Advisory diagnosis support service services’ /Dementia Advisors ( NB depends on local commissioned services)
Planning for the future Encourage Power of Attorney conversations, advanced care plans, wills. Consider early conversations around EoL; preferred place of care/death and DNR status End of Life planning in Dementia; Advanced Care Planning in Dementia . 95% of patients to have had a discussion about the future at their annual review principles Potential Ideas for Action Plan Resources Outcomes Planning for the present Consider each patient with Dementia at a meeting. Consider sharing a plan for each patient on the Shared Care Platform ( as used for the Avoiding Admissions DES) Consider regular meetings with a MDT to discuss patients on the register ( similar to Gold Standards Meeting) suggested attendees; GP, Practice Nurse, Dementia Champion, Local Carers support rep, District Nurse, Dementia Advisor/ CPN, social worker, pharmacist. To produce a Care Plan as required for the Avoiding Unplanned Admissions DES and publish on the shared care platform. Quarterly meetings with action plans and minutes /reports 85% to have a shared Care Plan on platform Appointment management Flag patient notes with an “alert” to offer a double appointment if appropriate Encourage patients to a carer/friend to appointment To send patient prior to appointment If patient’s DNAs, to proactively rebook an appointment 85% of patients to have notes “flagged” 100% of patients to have named clinician ( GP or Nurse) as key co-ordinator Post Diagnostic Support Service Consider referring patients on to dementia ‘post diagnosis support services’ /Dementia Advisors ( NB depends on local commissioned services) 95% patients made aware of the local Dementia Advisory service
Dementia%20Friendly%20Resources%20final.docx