This Template is the product of an inter-agency group in Devon, working with specialist consultation from Dementia Voice. The work was sponsored by Devon County Council through the Performance Fund.
The Template has the support of the Department of Health, and is recommended as a statement of principles for developing intermediate care services for people with dementia.
1.1 Person-centred dementia care focuses on peoples’ abilities rather than on their loss of abilities. It is important to reaffirm that many people with dementia are able to undergo rehabilitative processes and to relearn some abilities that have been impaired. People with dementia do however have additional needs that must be addressed to ensure access to Intermediate Care.
1.2 Impaired abilities: as each person with dementia is different from the next, the following will not apply to all, but many people with dementia will have to some extent a reduced:
- ability to recognise any deterioration or that they are at a time of crisis
- ability to understand and act upon altered care arrangements
- ability to communicate their wishes and opinions
- ability to learn new skills to replace any skills that have been lost
- ability to remain involved in any learning process
- awareness of potential risks.
1.3 A positive and person-centred response to people with these impairments is central to dementia care. Effective dementia care can also require additional time:
- many individual caring processes will take longer
- a longer time span from the start of any intervention until a planned outcome can be achieved.
1.4 The need for Intermediate Care: Intermediate Care is intended to help people at times of transition, frequently following illness, accident or some other major disruption to living arrangements. There are two additional scenarios in which a person with dementia may be in need of Intermediate Care, each of which is likely to require a specific response:
- Prevention: for many people with dementia, a time of transition is a consequence of a process that has taken months or years to develop. The scope of Intermediate Care should extend to include short-term interventions to prevent times of transition from arising
- Care diversion: people with dementia are frequently admitted to respite care or hospital in response to a crisis in their existing care. The person may be distressed, disorientated, and resistant to intervention. If staff do not have appropriate skills, the outcome is often admission to long-term institutional care, triggered by a failure to provide effective care and treatment, rather than by the original presenting crisis. To prevent this it may be necessary to develop a treatment environment more able to respond to the needs of the people with dementia at times of crisis.
1.5 While the needs of many people with dementia will differ from those of the general population, the majority of interventions will not be different. They will draw on the skills of medical and health care, therapies, social care and help with living arrangements. Intermediate Care for people with dementia therefore needs to be a carefully crafted combination of a variety of specialist inputs, informed by a full understanding of the needs of people with dementia.
1.6 Assessment: Intermediate Care follows from a robust assessment process. For people with dementia this is likely to be different in the following ways:
- The need to ensure that the person with dementia has understanding of their presenting and longer-term needs
- validation of views expressed needs to be sought by skilled communication with the person with dementia and at times from other sources
- The assessment is likely to require greater attention to social circumstances, living and support arrangements, and the needs and wishes of any informal carers
- An understanding of the role of any carer (their attitude to the caring role, their perspective of the situation of the person cared for, and what would assist them to continue caring) are essential to good assessment practice.
1.7 Consent: care has to be taken to ensure that a person with dementia gives informed consent to the initiation and continuation of any treatment or care, and to any change of living arrangements. Obtaining such consent can require skill and time.
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2.1 AIM The aim of Intermediate Care for people with dementia should be:
- To enable people with dementia to retain or regain abilities, where
the loss of these abilities would significantly change the quality of their life experience and/or living arrangements, and
such change would not be consistent with their understood wishes.
2.2 TARGET USERS The service should be directed towards people with dementia who would otherwise face significant and unwanted changes to their way of life, especially unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care, or continuing NHS in-patient care.
2.3 INTERVENTION STAGES Intervention will take place mainly at the two following stages:
- times of transition, i.e. when existing living and support arrangements are facing breakdown, and
- when current living and support arrangements indicate that intervention can prevent such breakdown.
Wherever achievable, intervention should be in, or as close as possible to the current home of the person with dementia.
2.4 TIME SCALES At either of these stages, intervention will:
- involve a rapid response to identified need
- be short-term, with the aim in each individual case of achieving agreed objectives.
It will not always be realistic to set a time limit as part of agreed objectives, but regular review will make it possible to set a time scale for withdrawal, and where necessary for transfer of responsibility to main-stream services.
2.5 OUTCOMES Interventions will respond to locality based needs and structures that are consistent with the principles defined in this paper. They will have measurable outcomes that are compatible with DoH reporting requirements.
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The following have been identified as key elements of Intermediate Care for people with dementia:
– interventions will be designed to meet the assessed and agreed needs of each individual person
– interventions will address the needs of the whole person, body, mind, emotion, spirit
- working with carers
– dementia care is a partnership between the person with dementia and any family or other carers. Informal carers may need to be offered training to enable them to fulfil this role
- multi-disciplinary, multi-agency
– interventions will involve people from a range of disciplines and agencies, informed by specialist skills in dementia care
- a culture of awareness and sharing
– where specialists in dementia care are involved, they will seek to support and enable other practitioners and carers who are not trained in dementia care
- consistent with existing practice
– Intermediate Care for people with dementia should be consistent with principles and practices as defined in the National Service Framework for Older People
- maximising independence
– interventions will have a planned outcome of maximising independence and typically enabling users to resume their preferred living arrangements. In some cases this will involve assessment and management of risk
- goal orientated
– interventions will be directed towards achieving identified and agreed goals
– the duration of interventions will be determined by achievement of goals rather than by time limits
- prevention and reablement
– interventions will aim to prevent breakdown in living arrangements and also to restore arrangements following breakdown
– users should experience minimum necessary change of personnel and environment
– termination of interventions will include linking with other services needed to provide continuing support
– interventions should be available to all people who could benefit, rather than to people who can only respond to any one form of intervention
- flexibility and availability
– interventions should be flexible according to identified needs and choices: this means flexibility in form of accessibility, intervention, provider, location and times of availability
– services must be able to change in response to changing circumstances.
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Dementia Voice is working with health trusts, local authorities and the independent sector to develop intermediate care services for people with dementia.
For further information please contact:
Chris Sherratt on 0117 975 4863 or e-mail email@example.com