1. The St George Dementia Model Shelly Ross, Kogarah Community Services Home Visiting/Dementia Respite Service & Raine Kornfeld, St George Carers Support Service

2. About the St George Area Comprised of Rockdale, Kogarah & Hurstville LGAs in South–Eastern Sydney Population of 210,000 (2001) with 15.5% over 65yrs Approximately 50% of residents speak a language other than English at home Largest language groups are the Chinese languages, Greek & Arabic

3. Why a Dementia Network? A number of agencies target people with dementia, their carers & families with different types of services There should be clear links and seamless pathways between these services Service types follow a logical pathway through the early, middle & later stages of dementia Formalising a network should enhance service providers’ ability to respond to client & carer needs

4. Three Stages of Dementia Early May be characterised by short term memory loss & confusion before diagnosis Middle Orientated towards stay–at–home strategies, behaviour mgt, respite & support services Later Development of individualised packages of services

5. Dementia Network Model Diagnosis Early Stage Intervention Education, Support & Activities Monitoring & Respite CACP/COP Community Awareness Media, Clubs, Schools, TAFE, Uni’s, Conferences, Seminars Enabling GP’s to assist their patients - through GP Education & Service Mapping LWML Program & Helpline ACAT – Family Dynamics Community Workshops Carer Support & Education Small Group Therapy Combined Weekend Trips Post-LWML meetings Day Care Centres In-home respite In-home monitoring Daily Living Support Preparation for Residential Care

6. 1st Tier – Community Awareness Aims To improve awareness of dementia To advertise existence of support services Targets General community Media Frontline intervention services Health professionals Community support services

7. Community Awareness Strategies Challenge “Dementia = no quality of life” Stress early diagnosis & appropriate intervention Mention the full range of services Advertise & draw on available resources Use existing communication pathways Piggyback onto existing initiatives & events

8. 2nd Tier – Diagnosis Recognises The importance of all in noticing signs of dementia GPs play a critical role in linking clients & carers to the other tiers The key role of CRAGS (ACAT) in assessment There are gaps in this tier including: A dementia specific brochure Bottlenecks in gaining diagnoses Access to support services in the interim

9. 3rd Tier – Early Stage Intervention Clients and Carers Need to know situation is under control May not need practical, external support yet Are supported to maintain their networks Are empowered through providing information and coping tools

10. Early Stage Intervention Includes: Living with Memory Loss Workshops Linking Carers to Carer Support Groups Outings & monthly bus trips for Clients Current Gaps Strategies focussing on the client Options for younger people with dementia

11. Includes both practical & emotional needs for support Client & carer must be ready to accept supports like: Support groups & short courses for carers Information & resource sessions & kits HACC & HACC like services Socialisation activities Recognises significant gap in low level domestic assistance 4th Tier – Education, Support, Activities

12. 5th Tier – Monitoring & Respite As dementia progresses monitoring & provision of respite becomes more important Carers should have access to: Planned, regular & on–going respite Emergency & short term respite In and Out of Home respite options Affordable respite Informal respite Access to comprehensive assessment & assessment for residential care, residential respite, COPS & CACPs is critical

13. 6th Tier – COPS,CACPs & Preparation for Residential Care Requires across & within agency teamwork to ease stress on the situation Transition to this tier must be planned & well co– ordinated Shared care is a central concept during handover periods with COPS & CACPs Quality case management is usually a feature CRAGS Placement Service assists with locating available residential care places Gap: Preparation for Residential Care strategies

14. Roles of the Dementia Network Information exchange Awareness raising of Model, its tiers & linkages Advocate for community understanding & sensitive service provision Develop & maintain seamless service pathways Identify system gaps, problems & blockages Act as problem solving forum Lobby for needed service & resources Participate in quarterly meetings

15. St George Dementia Network (1)

16. St George Dementia Network (2)

17. St George Dementia Network (3)