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Community-based dementia care

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VOL: 96, ISSUE: 45, PAGE NO: 40

Chris North, DipHE (mental health nursing), is senior primary nurse, community treatment team, Leeds

Dementia care has traditionally been seen as an institutional activity. As a team of nurses on a dementia assessment ward, we have successfully adopted a range of social, psychological and interpersonal approaches to care. Since the team's creation in 1994 our philosophy has centred on a holistic approach.

Dementia care has traditionally been seen as an institutional activity. As a team of nurses on a dementia assessment ward, we have successfully adopted a range of social, psychological and interpersonal approaches to care. Since the team's creation in 1994 our philosophy has centred on a holistic approach.

We were generally able to help clients reach a state of relative well-being within a few weeks, but it became increasingly clear that the benefits of this approach were difficult to sustain beyond three or four weeks after admission. The advantages of being in hospital, including personal safety and an undemanding environment, were soon cancelled out by the distress clients felt when they thought they were being kept away from loved ones and familiar environments for unjustifiably long periods.

We always aimed for an average admission of no longer than six weeks, but difficulties in securing ongoing community support often meant that our clients were in hospital for up to eight months.

The predictable impact of lengthy institutional stays meant that by the time community resources were available these clients needed intensive rehabilitation at home. In essence, those who were fit to return home after recovering from acute confusion were unable to get the support they needed and ran the risk of premature placement in nursing or residential homes.

Becoming community-based
We decided that one way to address the problem would be to convert our hospital-based team into an intensive community-based dementia support team. We had already been providing follow-up care, offering discharged clients and their carers advice, support and guidance, and believed that our client-centred practice would transfer relatively smoothly to a community setting. But once the new service was up and running some key differences emerged.

Visiting clients up to four times a day alerted us to the fact that our care had been more institutional then we had imagined. On a practical level, our community-based care plans had to start reflecting the living arrangements of each of our clients. On a logistical level, we had to identify who was responsible for problem areas such as a client's finances, medication and shopping. This is important in terms of preventing clients from becoming practically or emotionally dependent on our service.

On an interpersonal level we found we had to provide a good deal more rationale and reassurance to our clients about the service. We also found that although consent for an intervention in hospital was negotiated directly with the client, in the community it was necessary to liaise with, for example, GPs and social workers. In practice this has moved us into a comprehensive use of the care programme approach (Department of Health, 1996) for all clients, ensuring that all interested parties are consulted and that this is documented.

The project has been up and running for a year. In spite of a few surprises and the odd headache there have been some startling successes in preventing hospital admission and speeding up discharge.

As we learnt to adapt our core skills to the community, we also influenced others in providing person-centred approaches to dementia care. Providing a service in people's own homes and in residential and nursing settings, we have been able to advise, educate and supervise carers, including the demonstration of certain techniques.

This has enabled clients to stay in their homes with the people they want to be with.

As practitioners we have the satisfaction of knowing that about 75% of our clients no longer face potentially deskilling and distressing periods in hospital, with about 66% being placed in this position six months after our intervention.

Over our first year we have learnt how bewildering the range of physical health, mental health, social, home care and voluntary services must seem to clients and carers. Much of our work has been based on finding ways for our clients to feel that their support networks are enabling rather then threatening.

- See our careers focus, p48

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