Dementia

Advice on Dementia wellbeing during Covid-19 is available in the Downloads section.


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

Dementia Service (Formerly at the Diagnostic Memory Clinic at Felstead Street) 

The new CH Dementia Service (at Felstead Street) functions as both a Memory Clinic and Post Diagnostic Support Service.

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 jointly delivered as a collaboration between ELFT and Alzheimer’s Society with ELFT being the lead provider. It is a Consultant-Led service and aligned to Neighbourhoods with each neighbourhood having a named CPN and Dementia Navigator.

During the COVID-19 pandemic the Dementia Service is still accepting new referrals for memory assessment, and these should be sent via SPE/e-referrals. All patients with dementia currently open to the service are being reviewed and will have an offer of telephone support or face to face (depending on need). Dementia Navigators (Alzheimer’s Society) are increasing the number of keeping in touch telephone calls with service users.

Referral Pathways (Memory Problems, MCI, Post diagnostic & Pre-diagnostic Support)

The CH Dementia Care Pathway (hyper link) is also available on the right under pathways.

The CH Dementia Service operates a Single Point of Entry for ALL referrals which are triaged by a duty system. 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 service users diagnosed with Mild Cognitive Impairment (MCI) will be accepted from the GP.
  • All referrals for Memory problems. MCI and Post Diagnostic Support and Treatment should be sent to the Dementia Service (ELFT) Single Point of Entry on e-RS via emis. not Homerton Hospital. On e-RS select the speciality Mental health-adults of all ages>Memory Problems>ELFT City and Hackney Dementia Service. Alternatively, email elt-tr.mhcop.duty@nhs.net.
  • Conditions Treated
  • Organic neurodegenerative disorders, for example suspected dementia or mild cognitive impairment.
  • Please exclude mood disorder, or significant ongoing drug or alcohol misuse.
  • Please contact the service to discuss if clarification is required. 
  • Memory concerns in under 65's

Please consider Functional Neurological Disorder (FND) but if in doubt please refer and Dr Teper will screen the referral. If she concludes that this is not dementia or MCI, she will give feedback to the GP rather than arranging to review the patient. Here is a useful patient resource to explain FND

  • 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 refer to the Alzheimer’s Society by completing the Dementia Navigator Support Referral Form available in Downloads on the right.

Alzheimer’s Society also offers “Singing for the Brain” (currently via Zoom) - please make referrals by completing the Dementia Navigator Support Referral Form available in Downloads on the right.

Specialist Advice, Information and Guidance

Duty Desk (ELFT):                                                     020 3222 8500
Dementia Navigators (Alzheimer’s Society):             020 8533 0091
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.
Lead Consultant:                                Dr Emma Teper          email:  emma.teper@nhs.net
Operational Healthcare Lead             Adenike Saidu             email:  adenike.saidu@nhs.net


Neighbourhoods Dementia Practitioners (Post diagnostic follow up, advice and support)

Clissold Park and Woodberry Wetlands:
CPN:                           Alain Michel Nana                   email:  alain.michelnana@nhs.net

Dementia Navigator:   Ana De Genova                      email: ana.degenova@nhs.net

                                    Cilla Weekes                           email:  Cilla.Weekes1@nhs.net

Hackney Downs and Springfield Park
CPN:                           Diana Okoukoni                      email:  Diana.Okoukoni@nhs.net

Dementia Navigator:   Siobhan Cronin                       email:  Siobhan.Cronin1@nhs.net

                                    Amy Claringbold                     email: Amy.claringbold@nhs.net

Hackney Marshes and Well Street Common
CPN:                           Vacant                                     email: 

Dementia Navigator:   Claire Wheeler                        email:  Claire.wheeler@nhs.net

London Fields and Shoreditch Park and City
CPN:                           Christabel Kapochina             email:  Christabel.Kapochina2@nhs.net

Dementia Navigator:   Carol Feldon                           email:  Carol.feldon@nhs.net

                                    Joyce Tomlinson                     email:  Joyce.Tomlinson1@nhs.net

The Dementia Alliance (DA)

The DA provides expert knowledge and support and make recommendations for improved dementia care. It does this by bringing together key stakeholders and system partners from across health, social care, third sector and community groups to work in a more integrated and collaborative way to develop a sustainable, holistic approach to dementia care and support across the care pathways; reduce duplications and barriers to access.

Key Priorities 

The key priority areas for the Dementia Alliance are:

  • Carers Support – working with partners to improve support for carers of PwD
  • Care Navigation & Mapping – ensuring a well-coordinated approach to enable PwD navigate and access services
  • Care Planning; Urgent & Crisis Care – develop and inform new models of care that promote a well-coordinated access to care provision
  • Support for Care Homes, Housing with Care, Sheltered and Supported Living schemes

 

System Improvements

CMC Care Plans and Dementia Care

CMC 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 dedicated CMC & Data Quality Coordinator with responsibility to create CMC care plans.

Creating and Publishing CMC Dementia Care Plans

The Dementia Service creates and publish CMC care plans for:

  • All patients with dementia not currently on CMC
  • All patients with dementia following a diagnosis
  • Update existing CMC care plans where dementia diagnosis is missing 

To ensure created CMC care plans are approved and published in a timely manner by a clinician, in some instances, the CMC & 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 CMC & 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

Please find here information of all the reconciled Dementia Lists

Alzheimer’s Society, Primary Care (GPs), Homerton Hospital and Carers First lists with ELFT list to ensure data consistency across the system and to facilitate patients recall into the dementia service.

Following the lists reconciliation, the dementia service has written to GPs to request some clarifications and additional information where they have been some inconsistencies. Confirmation of the requested information will ensure accuracy of data across all systems.

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 Covid-19 Guide in different languages:

EnglishBanglaChinese, FrenchGreek, GujaratiPolishPortugueseRussianSpanishTurkishVietnamese

  • 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).