Integrated care for people living with memory problems.

People with dementia and carers allocated to the intervention arm will be referred to a Dementia Nurse. Dementia Nurses for this project will be employed by our Partner Organisation – Hunter Primary Care. The Dementia Nurse’s role will be to provide direct support to the person with dementia, their carer and GP/general practice nurse through care-coordination. The intervention will comprise: Assessing needs and priorities of the person with dementia and their carer (Dementia Nurse, person with dementia and carer. The nurse will conduct a home visit and complete a wellbeing assessment. This will assess the person’s need for additional help across a range of areas including mobility/ functional, health care needs, mental health and practical support. This is expected to take 1-2 hours and may be spread over 2 visits if required. The assessment will occur within 4 weeks of trial enrolment. The nurse will provide feedback on the assessment results to the person with dementia and their carer. A shared-decision making approach will be used to identify priorities for care planning. Case conference consultation (Dementia Nurse, GP and practice nurse). The Dementia Nurse will organize a case conference with the patient’s GP and practice nurse. Results of the Dementia Nurse assessment and any recommendations arising from this will be discussed. Facilitating timely communication across settings: The Dementia Nurse will recommend that the general practice nurse provide the patient and carer with a copy of the patient’s Health Summary. This is an automated summary that is produced by practice software that shows the patient’s key diagnoses and medications. They will be asked to advise the carer that in the event of an unplanned transition (e.g., ED presentation), they should provide the health summary to the treating doctor. Care co-ordination and integration (Dementia nurse). In line with any agreements with the GP and general practice nurse, the Dementia Nurse will follow-up on referrals to community programs, Dementia Australia, community nursing, and assist the person to navigate the aged care system. Brief interventions (Dementia nurse, person with dementia and carer, up to 4 sessions). The Dementia Nurse will provide up to 4 targeted sessions with the person with dementia and their carer. The focus of these will be informed by priority issues identified in the assessment and care plan. These are expected to be 45 minutes in duration and to occur monthly following the needs assessment. Review and second case conference (Dementia nurse, occurs 6 months post referral). The nurse will re-assess the person with dementia’s needs and discuss the adequacy of existing supports with them and their carer. This will occur 6 months post enrollment with the assessment taking 1-2 hours. The Dementia Nurse will contact the patient’s GP and offer to participate in a second case conference to feedback results of the reassessment as well as any other issues arising from the brief interventions delivered. This will occur within 4 weeks of the second needs assessment (i.e. 7 months post enrollment). Addressing carer needs. The intervention will address carer needs as well. Carers will attend Dementia Nurse sessions with the person with dementia and will learn strategies to support their family member at home. Care co-ordination aspects of the intervention will relieve the role of the carers in navigating the health system. Carers will also be supported to discuss, together with the patient, safety issues and planning for future healthcare transitions. If the carer is identified as being depressed or needing their own aged care services then the carer will be supported to access these. Carers will be able to contact the Dementia nurse with questions in between scheduled appointments and will be given information about where to access help outside of business hours. Delivery of the intervention will be completed by 7 months post enrollment for each participant. Patient management records kept by the nurse will be audited to determine whether needs assessment, case conferences and brief intervention sessions have been completed for each client.