DementiaNet

TOWARDS HIGH QUALITY, NETWORK-BASED CARE
With DementiaNet we aim to work towards high quality, network-based care. These networks will be organised on a local level, including healthcare professionals from medical, care and social disciplines. Collaboration is one of the keys to success, but remains a challenge to be organised. With our DementiaNet approach we take up this challenge to ultimately empower the patient, informal caregivers and all healthcare professionals involved to deal with the complexity of dementia. Hereby, we build upon experiences and lessons learned from previous projects related to quality improvement and collaborative care.

DEMENTIANET
DementiaNet improves local collaboration among healthcare professionals to provide care for community-dwelling elderly with dementia. Overall, the approach aims to reduce the burden of the disease for all persons involved in dementia care, including healthcare professionals, patients and their informal caregivers. Our mission is to deliver added value for patients, caregivers and society, by realizing an innovative cost-effective change in the care processes, realized by and fine-tuned for the locally collaborating professionals. We activate patients and carers, and start from their experiences and questions, which we adopt in line with network and system based methodologies.

• Coordination, collaboration and eagerness to improve are key words to form a DementiaNet team in which members join forces, complement each other, learn from one another and coach others - a team that wants to address the needs and priorities of the individual patient and caregiver. In short, DementiaNet is characterised as a step wise approach, together increasing
  Expertise in knowledge and competences among health and social care professionals;
• Collaboration, communication and coordination between care professionals;
• Patient and caregiver empowerment;
• Individualized care, tailored to each patients’ own situation, problems and needs.

Improving dementia care within primary care
The number of frail elderly with cognitive problems who are still living at home is very likely to increase. As a result primary healthcare professionals will increasingly be required to manage and optimise their treatment for patients with dementia. One of the top priorities among patients is to stay at home as long as possible within their own safe and comfortable environment. This underlines the need to improve dementia care within primary care.

Drawbacks to current dementia care
Although many initiatives have been designed over the past years, dementia collaborative care is still far from optimal, among others, because of a lack of expertise and sufficient training, and primarily because of low cohesion between different healthcare providers. Initiatives are merely implemented at a local level and this might be one of the reasons that quality of dementia care varies widely between different regions.

Despite the efforts thus far to improve care, there are still some drawbacks to current dementia care:

• Fragmentation of care; the choices in healthcare are extensive and (too) widespread, and there is a lot of overlap without offering complementary and well orchestrated services.
• Lack of individuation; care is insufficiently tailored to individual needs and is often not prioritised to meet these needs. Listening to the patients needs, and the caregiver’s experiences is not the cornerstone of dementia care in practice yet.
• Limited exchange between primary and secondary care; general practitioners and district nurses work from a general point of view, whereas specialised healthcare is not always available or is difficult to accommodate as structural collaboration with specialised centres is lacking.

Local networks: a tailor-made approach
DementiaNet facilitates the organisation, implementation and maintenance of local networks. This is done by offering education and support to local healthcare providers, in which practice-based learning, quality indicators, involvement of informal caregivers, and communication are central themes. Because the availability of services and healthcare professionals varies locally, one model will not fit all situations. Therefore, we tailor the approach of DementiaNet to each local network based on the services, healthcare professionals and resources available.

Professionals are invited to initiate collaboration with other healthcare caregivers. A core team will be designed, including medical specialists (GP, elderly care physician), care professionals (district nurse, case manager) and social domains (e.g. social worker). These networks will take part in quality improvement cycles and educational practice based training sessions. A self-assessment will be completed regularly within each network and data will then serve as the input for these quality cycles. As such, the network members themselves choose which topic they want to address and subsequently create their own improvement path with support of DementiaNet experts. Hence, the project entails the integration of several strategies to improve care, including innovative education and training sessions, quality cycles, and use of ICT tools.

Core elements
Our DementiaNet approach consists of several elements, including the following main components:

• Collaboration: we stimulate collaboration and train to the networks participants to improve their team competencies and communication skills, as well as taking responsibility for the joint improvement of dementia care.
• Leadership: without a leader, networks will not evolve. Therefore, we identify one or two professionals in each network to present themselves as leader of the network and specifically coach them to take on this role.
• Quality improvement: a self-assessment will be completed regularly within each network and data will then serve as the input for quality cycles. The network members select a topic they want to improve. For example, the recognition, diagnosis and treatment of dementia, or on how to organize multidisciplinary meetings.
• Communication: communication is important, in person as well as via digital route. We want to connect the patient and informal caregiver to the formal caregivers, to connect network members with each other, and to enable interprofessional communication between networks and expert centers.
• Practice based learning: we organize learning on the job to improve knowledge and competencies.
• To add value and safeguard a realistic business case of the network services by focusing on clear opportunities for increased cost-effectiveness.

More information? Contact us!
Please, feel free to contact our DementiaNet team in case you have any questions or would like to have additional information (e-mail: Minke.Nieuwboer@radboudumc.nl).