Dementia and frailty

cumbria icon North East and North Cumbria

A project to create the capacity for the sharing of information and the co-ordination of resource to deliver joined up care for those patients on the Dementia and Frailty pathways. Currently the key details are split across Health and Social Care, being held in multiple record systems, or on paper. This often leads to the citizen being asked for the same information, undergoing the same assessments, and even being admitted to hospital unnecessarily or against their will.

Also, within the Health and Care system there are ‘hand-offs’ from Primary and Community Care into Secondary Care and on to Tertiary services, with an incomplete picture of the person’s needs and circumstances. Delays in getting people back to their preferred location, against their wishes and their best interests, are frequently seen.

The proposal is to create the capacity to see all relevant information in a single record and to couple that with the ability to pass “packages” of information and data as the point of care changes. These packets of data will also be appropriately made available, for analytical purposes, to understand cohort trends and individual needs, and to inform how health and other care services can be configured.