1. Advanced Dementia Service - Bexley and Greenwich 1 st set up in Greenwich in 2005 Expanded to Bexley 2012 Aim to work with people with advanced dementia living at home

2. Why it’s needed People with advanced dementia often have complex physical and mental health needs Historically health services only get involved in a crisis Little advanced planning – despite knowing problems will occur

3. Unwanted outcomes Carers not sure who to refer to when changes happen Presentation at A&E / admission to hospital Admission to care home when not preferred option

4. Service in Bexley and Greenwich Oxleas funding part time CPN for a year Community Health Services provide community matron to work with CPN Dedicated psychiatrist time Caseload 25 people with advanced dementia living at home with carers

5. Service model Regular visits made by nurses Can arrange same day visit if needed in crisis Support to access equipment / other services Work closely with GPs

6. Kings Fund Research Project chosen by Kings Fund as demonstrator site for integrated working Outcomes to be presented summer 2013 Aim to secure funding to continue to project Meeting soon with Bromley Healthcare

7. Kings Fund Model of Care

8. Analysis from Greenwich Worked with over 100 people 75% admission avoidance Average time on caseload 483 days Supported carers to talk through end of life planning Positive feedback from carers – some set up charity ( www.hopeforhome.org.uk)