Case study: Coordinated care for people living with dementia

Luke Carter, a mental health nurse from Avon and Wiltshire Mental Health Trust, and Cheryl Wallace, manager Osbourne Court, a a care home in Bristol, have shown how carefully coordinated care can help people with complex dementia stay out of hospital.

Cheryl manages Osbourne Court, a 58-bed residential care home delivering care to individuals living with the whole range of dementia; from early onset fronto-temporal Lobe to advanced Alzheimer’s disease, including palliative care to end of life.

Luke is the assigned mental health nurse to support the home. For over two years, Luke has supported Cheryl in her care of residents through detailed planning of their care, advising on medication strategies and behavioural analysis. Detailed care plans involving home staff, occupational therapies and families are written to ensure the best outcomes for the residents.

Local GPs, liaise closely with all decisions and conduct annual reviews with all families. When required at crisis periods they willingly attend reviews with families to ensure all are informed and fully engaged.

This cooperative approach, based on an effective combination of NHS community services from Avon and Wiltshire Mental Health Trust, and a proactive GP surgery working with a capable home manager, has undoubtedly been key to preventing many upsetting and costly admissions.