Programme driver diagram

Focus on dementia

The driver diagram below is based on the learning from what worked in Focus on Dementia’s previous programmes. It shows the theory of change for an overall improvement programme for care co-ordination and provides some examples of change ideas. Not everything will be achievable or relevant for all services, but this diagram should be used as a motivator for improvement and for considering where the priority areas are for your service(s). The change ideas and measures are not exhaustive. We would recommend teams develop change ideas to fit their context and seek local quality improvement support, if available, in the development of additional measures as required.

A driver diagram for the post-diagnostic support and care co-ordination programme. It shows the programme aim, primary drivers and secondary drivers in three columns. The driver diagram also shows how the secondary drivers relate to the primary drivers.

Aim

People with dementia and their carers will experience quality care and support that is person-centred and co-ordinated from diagnosis to end of life.

  • More people report positive experiences of the care and support they receive.
  • People with dementia and their carers report experiencing joined up care and support.
  • Teams report improved and integrated working across health and social care and other community organisations.

Primary drivers

  1. People with dementia receive timely and equitable access to post diagnostic support.
  2. People with dementia receive care and support that is co-ordinated from diagnosis to end of life.
  3. Leadership and culture driving and supporting improvements.

Secondary drivers

  • No barriers to accessing PDS (for example, in care homes).
  • Quality improvement and assurance of PDS.
  • Staff with appropriate knowledge and skills.
  • PDS services connected to primary care.
  • Personal planning to promote independence and quality of life.
  • Proactive referral to rehab/enablement.
  • Support for carers.
  • Staff well-being valued.
  • Quality improvement and assurance of care co-ordination.
  • Staff with appropriate knowledge and skills.
  • Understanding of local population living with dementia.
  • Multi-agency/disciplinary working with robust communication, all sector contribution and awareness of roles and responsibilities.
  • Advanced dementia specialist support.
  • Care management of complex needs.
  • Proactive identification of PEOLC needs.
  • Access to specialist PEOLC as required. 

Change ideas

  • Data to support understanding population of people with dementia.
  • Conduct EQIA - to support equitable access for all to PDS and co-ordinated care.
  • PDS self-assessment using the QIF (and action plan).
  • Single quality question embedded into evaluation methods.
  • Improving the quality of personal plans.
  • Critical success factors for care co-ordination self-assessment (and action plan).
  • Create local dementia register.
  • PDS group work/peer support.
  • Co-ordinated and sustainable approach to promoting Excellence education across system.
  • Formalising PDS service connections with primary care - for example, PDS practitioner connected to primary care with ability to inform/update GP records.
  • Co-ordinated delivery (and recording) of PDS across all supports including community assets.
  • Create multi-disciplinary team with single point access for referrals, co-ordinated support and hub for info – all sector contribution and awareness of roles and responsibilities.
  • Referral triage, 5 pillars/8 pillars, to PDS/appropriate practitioner in team.
  • Self-referral system (for support when things change).
  • Technology - personalised technology prescription, for keeping connected (for example an App).
  • Formal connections with care centres and carer supports.
  • Implementation of the dementia and housing framework.
  • Implementing the Advanced Dementia Practice Model (ADPM).
  • Implementation of PEOLC ID tools.
  • Liaison with palliative care specialists.