York Dementia Care Coordinator Case Study

Reports are run on the clinical systems by the Dementia Care Coordinator at the GP practice to identify patients at risk of dementia. A patient was identified with suspected dementia however no investigation, assessment or formal diagnosis had been undertaken. The Dementia Care Coordinator contacted the nominated family representative who agreed to a home visit.

The patient has what is considered advanced dementia and received only half an hour care visit a day. The patient's family member was also caring for his other elderly parent who was mostly bedridden. They were putting off an important operation as this would result in them being unable to walk for some months after, and as the main carer this was a huge anxiety and cause of carer strain. The Dementia Care Coordinator liaised with the GP to review the patient for primary care diagnosis and the GP requested a District Nurse to undertake the necessary blood tests. A referral was made to Dementia Forward for family support. The complex care team were unable to get the patient a bed in a specialist care home for respite as there was no formal dementia diagnosis.

A case was put forward to the GP, containing all the evidence gathered from the home visit, conversations with the patient and collateral history from the family member. Once blood results were received which ruled out any organic cause for cognitive decline, a diagnosis was made. The support package has increased to four times daily and the family member is in regular contact with the Dementia Support Advisor. They can now schedule their operation knowing their parent will receive the support and care that they require. Annual reviews will now be undertaken by the GP surgery to monitor the patient and continuous care reviews will take place to ensure the care given is fulfilling the patient’s needs.