Welcome to the Dementia topic page. On here you will find information on the following:

1. Overview of the Dementia Service at Felstead Street
2. Referral pathways and dementia care pathway
3. Dementia nurses, navigators and support for primary care clinicians

1. Overview of the New Dementia Service model of care 
The new model of dementia care provides a diagnostic service that holds patients from diagnosis to death, or out of borough placement and ensures everyone living with dementia has a named practitioner to support them and their family throughout disease progression or as things change.
The current service is delivered by ELFT. It is a Consultant-Led service and aligned to Neighbourhoods with each neighbourhood having a named CPN and Dementia Navigator. Therefore, each patient will have a named dementia nurse or navigator (depending on level of need) who patients, care givers and professionals can contact for support (see contact details at bottom of page).

2. Referral Pathways and dementia care pathway (Memory problems, MCI, Post diagnostic & Pre-diagnostic Support)
The CH Dementia Care Pathway (hyper link) is available on the right under pathways and offers detailed flowchart of patient journey.
The CH Dementia Service operates a Single Point of Entry for ALL referrals which are triaged by a duty system. Please ensure referrals are sent using the referral form (on EMIS or here on the right) and sent to the Dementia Service (ELFT) Single Point of Entry on e-RS via emis (not to Homerton elderly care).  Alternatively please email email elt-tr.mhcop.duty@nhs.net The service is open from 9:00-17:00, Monday to Friday.
•    Referrals accepted for service users who are 18+ years old and registered with a GP in City and Hackney.
•    Referrals for service users with a suspected dementia accepted only from:

• GPs, Community matrons (GP completes dementia blood screening and GPCOG Test)
• Homerton University Hospital (e.g. patient has been inpatient or has been seen in a specialist clinic)
• Other specialist clinics e.g. Parkinson Clinic  
• Referrals for service users who already have a diagnosis of dementia can be from anyone including self-referrals.

Referrals for suspected dementia/cognitive impairment:
•    Please use the referral form embedded on EMIS for all referrals. For all referrals please consider:

• There should be evidence of cognitive impairment for at least four months
• Screen for mood disorders (depression/anxiety/grief) and if present consider trial of treatment for three months prior to referral
•  Alcohol/drug screening – if drinking >14units alcohol per week consider advising reduction and monitoring for three months prior to referral
• Physical causes/delirium considered (infection, recent stroke, metabolic problem, poor nutritional status, medication review)

•    If there are complicating factors or queries please discuss the case prior to referral with the dementia team consultants on elt-tr.mhcop.duty@nhs.net.
•    For patients <65 dementia is much less likely. Please screen for mood, sleep, menopause and significant family history. Consider discussing these cases directly with memory clinic consultant (elt-tr.mhcop.duty@nhs.net) as these patients may benefit from discussion with/direct referral to neurocognitive disorders unit at Queens Square or alternative pathway. 

•    Referrals for Pre-diagnostic support ONLY (Patients for whom there is a concern of memory problems but who are not engaging with GP or have declined referrals to the dementia service) Please discuss directly with your neighbourhood Dementia Navigator (contact details at bottom of page) or discuss directly with Dementia Service for advice.

3. Dementia nurses, navigators and support for primary care clinicians:
Dementia Nurses role:
•    Post diagnostic support 

• To manage a caseload of service users and their carers / relatives supporting them through the diagnostic process, providing post diagnostic support and follow up diagnostic care, in line with local protocols and evidenced-base nursing care
• To actively monitor deterioration using a risk stratification tool - Activity of Daily Living, mood, cognition, general health and safeguarding) 
• Actively engage people with Dementia and Cognitive impairment and their carers in all stages on intervention, ensuring that their views are acknowledged and taken into account To liaise and work closely with linked Social Workers in Neighbourhoods to facilitate timely provision of social service input including formulation of joint crisis plan
• To promote the needs of service users with mental health needs and Dementia, providing training and psycho-education whenever possible
• Provide review of dementia medication efficacy both at the service and home visits where appropriate for patients starting medications and make recommendations to GP 

Dementia Navigators role:
Dementia Navigator work in a fully integrated way as part of City and Hackney Dementia Service multidisciplinary team to help maximise identification, engagement and support for service users, carers and families with dementia illness. 
The Navigators offer comprehensive information, post-diagnostic support, and advice around the processes for screening / diagnosing dementia, the benefits of engaging with the service to facilitate timely diagnosis, what to expect during the screening and diagnostic processes and the support they can offer.
The Navigators can provide support to GPs in managing service users who are not engaging, and build / develop strong relationships between the Navigator, GPs and other practice staff through the provision of education, information and awareness raising. This can include co-locating in GP practices and joining appointments (where appropriate) to listen to patients/carers concerns that are causing them not to engage; explain the screening / diagnosis process, provide information and advice about dementia and answer any questions. 
Please use the provided contact details below to liaise with your neighbourhood navigator for pre-diagnostic or post-diagnostic support.

Specialist Advice, Information and Guidance
Duty Desk (ELFT):        elt-tr.mhcop.duty@nhs.net 020 3222 8500
Lead Consultants:      Dr Emma Teper (currently unavailable)
Dr Nodira Nastritdinova (Tues/Thurs/Fri AM) email: nodira.nasritdinova@nhs.net 
Dr Chloe Pickup (Mon/Tues/Wens) email: chloe.pickup@nhs.net
Operational Healthcare lead:    Adenike Saidu email: adenike.saidu@nhs.net
Alzheimer’s Society National Dementia Connect Support Line: 0333 150 3456. Phone support available 7 days a week. Mon to Wed: 9am-8pm; Thurs & Fri: 9am-5pm; Sat & Sun: 10am-4pm. More information here.

Clissold Park and Woodberry Wetlands:
CPN:     Alain Michel Nana (alain.michelnana@nhs.net)
Dementia Navigator:  Cilla Weekes (cilla.weekes1@nhs.net)
                                        Erin Bradford (erin.bradfrod@nhs.net) part time

                                    
Hackney Downs and Springfield Park
CPN:   Diana Okoukoni      (Vacant from the 8th of September. Recruitment in progress)        
Dementia Navigator:   Amy Claringbold (amy.claringbold@nhs.net)
                                         Adi Zeira (starting date to be confirmed)
                                         

Hackney Marshes and Well Street Common
CPN:       Helen Onwualu ( helen.onwualu@nhs.net)     
Dementia Navigator:   Oktawian Janicki (oktawian.janicki@nhs.net) starting October 2023

London Fields and Shoreditch Park and City
CPN:                      Gemma French (gemma.french2@nhs.net) 
Dementia Navigator:   Carol Feldon (Carol.feldon@nhs.net)
                                        Joyce Tomlinson (Joyce.Tomlinson1@nhs.net)

Universal Care Plans and Dementia Care
Universal care plans are now applicable to all patients with dementia to facilitate better crisis management by urgent care services especially out of hours. The dementia service has a responsibility to create these urgent care plans.

Creating and Publishing Universal Dementia Care Plans
The Dementia Service creates and publish universal care plans for:
•    All patients with dementia who do not have an urgent care plan
•    All patients with dementia following a diagnosis
•    Update existing urgent care plans where dementia diagnosis is missing 
To ensure universal care plans are approved and published in a timely manner by a clinician, in some instances, the Data Quality Coordinator may need to liaise with GPs for some or all of the following mandatory information:
•    Prognosis Details
•    Preferences - Preferred Place of Care and Preferred Place of Death
•    Cardiopulmonary Resuscitation (CPR) Discussion
•    Ceiling of Treatment
The Data Quality Coordinator will also require GPs to confirm if a discussion has not taken place yet with the patients and or their families.
For more information, please contact Andrew Whipp. Email: Andrew.whipp1@nhs.net

Useful Resources for Patients, Carers and Families
Please find here some useful resources for patients and families
•    Dementia Fact Sheet- you can download and print off free fact sheets from the Alzheimer’s Society website.
•    CH Dementia Carers Guide
An information and support guide for carers, families and friends of people living with dementia (also available in Downloads).
•    CH Guide to Dementia and Family Relationships
A guide to help families understand and manage dementia in the family (also available in Downloads).
•    Dementia Telephone Communication Tips
Simple tips for professionals on how to communicate with people living with dementia over the phone (also available in Downloads).