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Changing practice

Integrated care pilot programme: ensuring people with dementia receive joined up care  

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The government is piloting several models of integrated working in health and social care. A nurse led pilot improved support for older people with dementia



Kate Jones, BSc, RMN, is nurse team lead, Bournemouth and Poole integrated care pilot.



Jones K (2010) Integrated care pilot programme: ensuring people with dementia receive joined up care.Nursing Times; 106: 10, early online publication.

The Department of Health’s integrated care pilots, announced in April 2009, aim to transform the way people experience health and social care. A multidisciplinary team in Bournemouth and Poole has set up a nurse led project focusing on memory loss and dementia in older people. This article outlines the aims, elements, challenges and benefits of working as part of a multidisciplinary team, from a nursing perspective.

Keywords Integrated care pilots, Dementia, Older people

  • This article has been double-blind peer reviewed


Practice points

Services considering implementing a similar programme should:

  • Understand their local population and identify unmet needs;
  • Involve nurses and other healthcare professionals in the initial planning and service design period;
  • Set clear objectives and measurable outcomes;
  • Promote integration as a team philosophy;
  • Devise the most effective, efficient way to integrate working practices to offer a seamless service for clients and review its success regularly;
  • Review outcome data regularly and frequently to enable improvements to be implemented at the earliest opportunity.




The Department of Health announced 16 integrated care pilots (ICP) in April 2009, aimed at testing different models of integrated working in health and social care. The pilots, which are located across England, will run for two years and be evaluated against a set of national and local measures (DH, 2009a). Together, they will test a number of diverse models, focusing on innovation, improving quality and patient satisfaction.

Bournemouth and Poole Community Health Services is an ICP initiated in September 2009 and coordinated by Bournemouth and Poole PCT and Bournemouth and Poole local authorities. As a community based model, it is designed to improve early intervention and signposting to services for people with memory loss and diagnosed dementia.

The multidisciplinary team includes GPs (four local surgeries are involved in the project), acute care consultants, specialist nurses, social workers, mental health intermediate care assistants, a dementia support worker, third sector agencies and local community groups.

Bournemouth and Poole has a higher percentage of older people than the English average. The proportion of people aged over 60 is approximately 25% in Bournemouth and 27% in Poole, and 8.5% of the population of both areas has dementia, according to the Projecting Older People Population Information System.

Aims and objectives

In the Bournemouth and Poole areas, healthcare professionals identified that a number of people with memory problems were not being fully supported to manage their health and wellbeing effectively. Historically, local GPs would refer people presenting with short term memory problems to the community mental health team. However, this team did not primarily focus on those with low level needs who did not require ongoing support from a community psychiatric nurse (CPN). This resulted in a number of people living unmonitored in the community, with no way of supervising their health, or dealing with any deterioration until it presented as a crisis, often in a hospital admission.

Developed from the national dementia strategy (DH, 2009b) and taking guidance from the Transforming Health and Social Care agenda (DH, 2009c), this ICP project aims to draw up an effective local dementia pathway that joins up health and social care.

It aims to offer high quality, person centred specialist care that responds specifically to the needs of people with memory loss and dementia. A fully integrated, community based team offers both crisis and low level care to improve interventions for service users, ensuring that often “hard to reach” residents access appropriate services at the earliest opportunity. As part of this, the team hopes to increase the number of people listed on GPs’ dementia registers. It also aims to provide support and interventions to prevent hospital admissions, speed up successful assisted discharge and to work with service users and carers to enable people to remain in their own homes.

The ICP team also plans to engage local businesses and community networks to raise awareness of memory loss and provide an informal infrastructure to support the project. This includes proactively promoting the scheme and communicating the benefits to the local economy of supporting service users (and carers) to remain in their own homes.

Establishing a multidisciplinary team

The pilot has three main elements. The first has involved establishing a multidisciplinary intermediate care team to proactively identify clients, using GPs’ registers for carers, vulnerable people and dementia, together with hospital admission lists. The team has developed a clear pathway to enhance patients’ experience. The aim is to test the effectiveness of the pathway and the supporting organisational structure, to deliver better care and effective use of resources.

A nurse lead manages the integrated team, and coordinates team roles for both health and social care professionals. This includes managing a social worker, registered mental health nurse, mental health intermediate care assistant and dementia support worker. The team leader assesses all referrals and, depending on physical health concerns and mental health issues, allocates the first assessment to an appropriate team member(s).

The pilot receives referrals from the four GP practices involved. At the beginning, the team presented the structure to GPs, outlining the new service and how they could make referrals. In October, the project’s first full month, the team received 46 referrals. These included one-off assessments for low level support or urgent care requests which are referred to the ICP team social worker and then on to the team’s care assistant for immediate implementation.A client could be in the team’s care for up to six weeks at a time, or for more short term care, such as when a carer is ill and the client needs prompting to take medication or help with personal care. While the team deals with immediate issues, it also considers any longer term care that might be needed in the future, potentially from mainstream social services care or floating support facilities.

Local GPs have so far been enthusiastic supporters and found the system beneficial, particularly because of its joint approach. The ICP team works in a truly integrated way, with social care staff and healthcare professionals taking equal responsibility for liaising with district nurses and GPs.

Working with the voluntary sector

One of the activities launched as part of the pilot is a monthly “Singing for the Brain” club, which was developed by the Alzheimer’s Society. The club is run by the dementia support worker and a mental health nurse, and aims to provide both therapy and social activity for people with dementia and their carers. It provides an opportunity to participate in enjoyable singing sessions in an informal and friendly setting, which stimulates the mind and body. Using music, one of the earliest human memories, clients often find they remember tunes and lyrics and this helps them to remember significant portions of personal history, as well as helping them learn to socialise again.

Working with a dedicated dementia support worker

The pilot’s second element is a dedicated dementia support worker, who acts as a key worker for people identified with memory loss. Seconded from the Alzheimer’s Society, the key worker provides a low level of ongoing support for clients with early memory impairment, such as education and plans for crisis management. This is an ongoing process, which might mean the key worker refers clients back to the team if their condition deteriorates and they need a higher level of support to avoid a future crisis.

Local service users have responded well to this service, all benefiting from one to one, continuous support. They are able to develop relationships with the dementia support worker, who has been particularly successful in engaging some of the most distant male clients. The support worker takes a personalised approach to building relationships, which might include taking a client out for a coffee or playing snooker in a local club.

Another part of this role involves completing life diaries for clients. These consist of clients’ personal details, contact information for friends and family, favourite media such as television or radio programmes, personal history, as well as hobbies and interests. By capturing such information early on, if clients need a higher level of care in the future, particularly in residential settings, they have a personalised booklet outlining who they are and their life history.

One example of how this has helped to provide personalised care is a male client living in residential care, who used to be a milkman. He would wake up at 4.30am every day and, without a life diary, care staff would have encouraged him to go back to bed. However, thanks to the care diary they knew getting up early was ingrained in his behaviour and would not change, so they could accommodate his habit. 

Engaging the local community

The third element of the project involves developing new and innovative ways of delivering low level dementia support for service users and carers, using partnerships with the third sector, local businesses and existing community networks.

The nurse lead is developing relationships with a range of community stakeholders to ensure the wider community can contribute. At the beginning of the project, leaflets were produced and a community launch event was organised so local businesses could get involved. The event, which was well attended, allowed the ICP team to talk about the project and open communication so local businesses could refer people they were concerned about.

It also allowed the team to pass on advice about how to manage clients with memory difficulties who might visit local shops, and helped to address the general stigma of dementia. Consequently, local pharmacies have become involved, as well as a local bank.

Since the launch event, a local café owner has offered to set up a memory café, to complement the existing three held in a village hall, church hall and local library. Attended by around 20 people, these informal sessions take place once a month and are run by the dementia support worker and the mental health intermediate care assistant. A local guest is invited to each session, and these have included local police officers and police community support officers who distributed handbag ties to tether a purse or wallet to a bag.

The ICP team also works with other partners, such as Rethink (Borough of Poole Social Services), a floating support service for people with dementia. Two allocated workers from Rethink provide support to people who need lower level assistance with non personal care activities, such as shopping, household tasks or help with financial affairs, free of charge. Faithworks Wessex, a local faith group, also offers a service to carers, which includes emotional support and companionship. The ICP team has used this service with successful results.

Nurse involvement in pilots

The ICP project has benefited from high involvement of nurses from a range of disciplines, including mental health and community nursing. The nurse leader has developed team management and coordination skills, and all team members have benefited by learning from professionals from other disciplines. The pilot has also allowed nurses to become involved with new areas of the community, such as local businesses and third sector partners.

Nurses have found that their experience of using reflection techniques, particularly in team meetings, has helped to consider both the short and longer term needs of clients. Working in an integrated way has also allowed each team member to build confidence, giving greater decision making power as a team, while also allowing flexibility to change direction if a client’s condition deteriorates.


Due to its innovative nature, the ICP has encountered some challenges. Initially, confronting stereotypical views of dementia was an enormous challenge, but initiatives such as local business engagement are helping to educate local residents. Community engagement is time consuming and requires frequent communication to maintain momentum.

The team is conscious of future capacity issues, particularly for the dementia support worker role. The national dementia strategy (DH, 2009b) requires every patient to have a single point of contact. However, the current level of monthly referrals and the fact that clients remain on the support worker’s caseload until they die means it could become unmanageable. This situation is being monitored on an ongoing basis.

Another issue is how to effectively engage clients who do not require services immediately but may do so in the future. Many do not have any insight into their current or future needs; they may be able to make the decision not to request support immediately, but they may lack the capacity to change that decision in the future. In the past, teams might have completed a capacity assessment and concluded there were no immediate needs and so that particular client was lost from the system. The ICP model involves recording such clients’ details, and then a team member revisits them after a suitable interval, to assess health or care requirements.

Early results and benefits

The ICP programme has allowed an adequate level of resources to become available, which allows the team to respond to proactive and reactive needs and take both a short and long term view. With an intermediate care assistant available, clients can receive care as soon as they need it. Wider healthcare resources also available to the team include occupational therapy and physiotherapy support from the team at Woodlands Intermediate Care Unit, the psychiatric liaison teams in both Bournemouth and Poole acute hospitals and the Bournemouth (Kings Park Hospital) and Poole (Alderney) Community Mental Health Teams. The team can also direct clients to the third sector organisations Age Concern and the Help & Care voluntary agency. It also works closely with the Poole Intermediate Care Service team and refers clients to the Community Assessment and Rehabilitation Team in Bournemouth. Both local authorities are actively involved in the project.

Team members feel the integration model has been extremely successful, with GPs, other health and social care professionals and agencies, including third sector organisations, working together effectively. Anecdotally, the team has also received supportive comments from clients, carers and relatives by telephone and letter. The case studies in Boxes 1 and 2 show how the ICP team has supported clients.

Box 1. Providing carers

A local couple referred themselves via the social services helpdesk. Social services informed the ICP team, who provided an immediate response which averted a crisis. The woman had diagnosed dementia but the couple did not have any care, support or family. The social worker conducted an assessment and the team provided carers to help the woman with her personal care needs, along with support from the Poole Intermediate Care Team, a general nurse (due to some physical health issues) and physiotherapy support.

The couple wanted to write an advanced care plan, with advanced directives, due to their lack of family. The social worker contacted a local solicitor who is now completing advanced directives for both. In addition, the dementia support worker is providing ongoing low level support and completing life diaries with both clients.


Box 2. Improving quality of life

The team’s first referral was a single woman aged 80 who had undiagnosed dementia and lived alone with no family, children or friends. When the GP referred her, she had an unstructured daily routine and was low in mood. She did not go out to shop for food and team members were concerned about her wellbeing.

The team completed an assessment, including the basic physical health assessment of dementia screening, blood and urine, to assess any reversible causes of confusion. They went on to complete an in depth mental health assessment and discussed it with her GP. The team (via the GP) referred the client to the local memory clinic service at the community mental health team, where she was diagnosed with Alzheimer’s disease and started donepezil treatment.

The team’s carers now regularly support her, and she attends the memory café and goes shopping with carers once a week. Her mood has improved and she is able to lead a much fuller life. The memory clinic CPN and ICP mental health nurse constantly keep in touch with each other to provide updates and ensure the client receives optimum care.


Ongoing evaluation

While the project is still in its early stages, a rigorous evaluation system has been put in place to measure and track results, in one joined up IT system, which can be accessed by all ICP partners.

The DH has set up performance indicators and as part of the project a data analyst collates monthly data, which the team can access to identify successes and areas for improvement. Information includes where a referral has come from, the diagnosis, any relevant hospital admissions or residential care information. Indicators include whether the team has prevented a patient going into hospital or residential care, as well as minimising risk and support.

Monthly assessment will continue until the end of the project in August 2011, when recommendations will be made on how learning from the ICP programme can be implemented on a wider scale.


  • A community based, integrated care pilot (ICP) was set up to focus on delivering low level support to clients with dementia in the Bournemouth and Poole area.
  • The project includes developing a local dementia pathway, providing a dementia support worker and a community engagement programme.
  • Research is being carried out to measure the pilot’s success to improve early intervention, signposting services to clients and reduce hospital admissions.


  • Due to the success of these pilots the DH announced an expansion in February 2010, to enable more sites to set up projects in a range of sectors, such as children’s services, education, criminal justice and housing. To apply click here.


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