Evaluation of an integrated service delivering post diagnostic care and support for people with dementia and their families.

Greater integration of health and social care services is considered vital to ensure sustainable long term quality provision for the growing numbers of people living with dementia and their families. Integration of services is at the heart of government policy in England. We evaluated a new integrated service for post diagnostic dementia care, funded as a pilot and delivered through a partnership of statutory and voluntary sector health and social care organisations. The service used an adapted Admiral Nursing service model with a workforce of Admiral Nurses (ANs) and Dementia Advisers (DAs). A mixed method approach was used to assess implementation and outcomes. It involved: collection of service activity data; carer reported experience survey data, focus group discussions and interviews with the service delivery team and the management group. Qualitative data was analysed used a framework approach. 37.8% of the eligible population registered with the service over the 14 month pilot period. The self-referral route accounted for the majority of referrals, and had enabled those not currently receiving specialist dementia care to engage with the service. Carer satisfaction surveys indicated high levels of satisfaction with the service. The caseload management system offered specific benefits. Individual caseloads ensured continuity of care whilst the integrated structure facilitated seamless transfer between or shared working across AN and DA caseloads. The skill mix facilitated development of the DA role increasing their potential contribution to dementia care. Challenges included managing large workloads and agreeing responsibilities across the skillmix of staff. This model of fully integrated service offers a novel approach to addressing the problems of fragmented provision by enabling joined-up working across health and social care.