Forth Valley Dementia Outreach team offers rapid response for families

In the future, that could result in more admissions to wards at an already busy Forth Valley Royal Hospital.

Some 4700 people in the Forth Valley area have been diagnosed with demntia and scores of others are likely living with the condition.

It is an illness which not only causes distress and anxiety for those diagnosed, but also their families, carers and loved ones – which could end up weighing heavily on the local health service too.

Luckily, though, there is a small but dedicated team working hard to mitigate issues in the Forth Valley area ... before they reach crisis point and result in hospital admissions.

The Dementia Outreach Team (DOT) is available for people with a diagnosis of dementia, accessed through their GP or social worker.

A rapid response team, it was established by NHS Forth Valley to support care at home for patients with dementia and their carers.

Based at the community hospital in Stirling for its first three years, the team outgrew that base and moved to a new home in Airth Health Centre in July.

Alzheimer Scotland will very shortly be setting up a base in the neighbouring unit which will further help to join up local services.

But the seeds of the project were sewn long before DOT was established in 2016.

Frank Carlin, NHS Forth Valley charge nurse for dementia, talked us through the project’s history.

He said: “The outreach team evolved out of the dementia link nurse service, initially staffed by Alister Edmond who covered the whole of the Forth Valley.

“At the start of 2005, I was appointed to cover Stirling and Clackmannanshire.

“Our sole remit then was to monitor patients’ response to a number of dementia medications.

“But we discovered that people didn’t just want to speak about medication; they wanted to see us in times of difficulty.

“We also only ever saw patients who were receiving medication, so there were a lot of people living with dementia who we never crossed paths with.”

In consultation with the nurse manager, consultant and NHS Forth Valley, Alister and Frank made the case for a different approach and, in 2016, that saw the link nurse service evolve into the Dementia Outreach Team.

Although Alister retired last year, he was able to see the fruits of their labour in action.

Frank is now supported by fellow charge nurse Angela Kane, two staff nurses, two health care assistants and a Stirling Council social worker, with plans for Falkirk Council to appoint one too.

It’s still a small team to cover the whole of the Forth Valley area but they pride themselves on dealing with situations quickly, with the aim of preventing unnecessary admissions to the area’s hospital.

Frank said: “We aim to visit the person within two working days of referral to head off crisis situations, whether that be for the patient, their family or carer.

“Outreach nurses carry out a comprehensive assessment and provide advice, practical assistance and support to patients, family members and carers.

“Our aim is to avoid what could become a crisis and, wherever possible, prevent the patient having to be admitted to hospital.

“If people need help urgently, we can get someone out to them quickly.

“The first referral needs to come from their GP or social worker.

“However once we have worked with a family, if they need our help again, they can self-refer back to us.

“They don’t have to go back to their GP if they hit another bump in the road – they can call us any time.”

The service works from 9am to 5pm, Monday to Friday, offering intensive support for an initial six-week period, after which the patient’s care and support package will be reviewed.

Frank said: “Our aim is to ensure that people who have a diagnosis of dementia have as good a life as possible.

“Carers’ stress is a big issue which is why we are there for the whole family and not just the patient.

“It can become more and more difficult for a husband, wife, son or daughter to look after someone with the illness so we’re there to offer them support and advice too.

“We can also signpost them to other agencies that can help, such as the Falkirk Carers Centre.

“When people are in crisis, they don’t want to wait eight to 12 weeks to see someone.

“That’s why we aim to see new referrals within a couple of days and because we have a multi-disciplinary team, it brings services together to make life easier for patients and carers.”

As dementia affects people in so many different ways, often knowledge is a powerful tool.

Frank explained: “We can provide information about the illness and strategies for coping with it.

“With dementia, one size does not fit all – everyone has different problems.

“That’s why the service is tailored to meet the patients’ and families’ needs, rather than being based on what we think they need.”

The new premises in Airth were crucial to the team and Alzheimer Scotland moving in next door is also a bonus.

Frank said: “In Stirling, we’d outgrown the space.

“The Airth premises are ideal for our needs now and we’re delighted that our colleagues from Alzheimer Scotland are moving in as it will make it easier to interact with them too.”

In the last three years, the outreach team has helped hundreds of local families facing crises but, often, they see the same patients, time and again.

Explaining why, Frank added: “We’re here to help improve the quality of people’s lives but dementia is a progressive illness, so we do tend to see people again and again.

“We’re not a massive team which is why we dip in and out; we help families overcome problems until they need us again.

“It helps to streamline the process if we can help not only the patient but their carers and families too.

“Families want help when they need it and I’d like to think we’ve achieved that in the last three years.”