The Peri-Dementia Diagnostic Service (PoDDS): a study protocol for a nurse-enhanced primary care service.

Abstract

AIM: CDAMS is the public dementia diagnostic service in western Victoria. 70% of people with dementia live in the community with one-third of people with dementia particularly vulnerable as they live alone. During the CDAMS assessment people who are poorly connected with health and social services, including General Practice, are referred to PoDDS, a nurse-enhanced-service supporting people through the diagnostic process. Methods: PoDDS will be developed using an iterative PDSA methodology. PoDDS is supported by an existing care coordination and support system, and funding sits within the Hospital Admission Risk Program (HARP), at Ballart Health Services (BHS). PoDDS will work with the target group of clients as they are accepted into the CDAMS. PoDDS is a time-limited service with the PoDDS nurse providing person-centred care including education and psycho-social-health care planning for people in the adjustment period prior to, during, and after receiving the diagnosis of dementia. Results: The feasibility and sustainability of PoDDS within the current organisational resources and funding models will be measured by collecting data on the number of patients using the service, hours of contact per patient, funding generated. Patient experience of the service and health outcomes will be measured using the quality of life measures and qualitative interviews. CDMAS geriatrician, PoDDS nurse, General Practitioner and Practice Nurse experience of the service will be collected through interview. Patient hospital presentations and admissions will be collected and compared to PoDDS involvement. PoDDS processes and procedures will be evaluated against best-practice dementia care guidelines. Conclusion: Include: an innovative model of community care supporting marginalised, vulnerable populations; increased identification, efficiency and effectiveness of care in the lead up to, and post dementia diagnosis; person-centred care plan 'handed-over' to General Practitioner and Practice Nurse for on-going care; a reduction in fragmentation and barriers to care.