Peri-Dementia Diagnostic Support Service (PoDDS):
A quality improvement study
In current practice, following diagnosis in the Cognitive Dementia
and Memory Service (CDAMS) the person is directed to the General Practitioner to provide support and on-going management.
However, it is well acknowledged that post-diagnostic care for people with dementia and their families is poorly managed. (1) Reasons include:
• significant barriers to dementia care exist in General Practice (2)
• co-morbidities in people with dementia are often under- diagnosed and under-treated (3)
• people with dementia experience difficulties accessing appropriate information and services (4)
Inadequate dementia care following diagnosis potentiates the risk for inappropriate management, poor psychological adjustment and reduced coping capacity and ability to forward plan. (4)
Caroline Gibson
1, Mark Yates
2, Melinda Farnsworth
11 Ballarat Health Services
2 Ballarat Innovation & Research Collaboration for Health
This project is an Australian Primary Care Nurse Association Building Nurse Capacity – improving patient outcomes. Funded by the Australian Government Department of Health under the Nursing in Primary Health Care programme 2018-2022.
References
1. Kelly F, and Innes A. (2016) Facilitating independence: The Benefits of a post-diagnostic support project for people with dementia. Dementia. 15(2):162-180 2. Phillips, J., Pond, D., & Goode, S. (2011) Timely diagnosis of Dementia: Can we do better? A report for Alzheimer's Australia. Paper 24
3. Bunn F, Burn A, Goodman C, Robinson L, Rait G, Norton S, et al. Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem). Health Service Delivery Research.
2016;4(8).
4. Duane F, Goeman D, Beanland C and Koch S. (2015) The role of a clinical nurse consultant dementia specialist: A qualitative evaluation. Dementia. Vol. 14(4) 436–449
5. State of Victoria, Department of Human Services (2008). Health Independence Programs Guidelines. Victorian Government Department of Human Services, Melbourne, Victoria, Australia
Study purpose
The opportunity
The Hospital at Risk Program (HARP) aims to:
• reduce avoidable admissions and presentations to hospital
• manage people with chronic disease, aged and/ or complex needs to improve patient outcomes
• provide integrated seamless care within and across hospital and community sectors.
Both CDAMS and HARP are Health Independence Programs
(HIP). HIP guidelines state that a person is to receive the right care, in the right place, at the right time, unhampered by
program boundaries. (5)
Integrating care: PoDDS
A better client journey (adapted) (5)
Access and initial contact
Initial needs
identification Assessment
Care planning and
implementation
Monitoring and review
Transition and exit