Dementia Care and Support Planning Generic Toolkit

Dementia Care and Support Planning Generic Toolkit

Soon after diagnosis, patients should be encouraged to complete a “This is Me” document. Dementia Advisors can support people to complete this form. “This is me” is a personal approach to record details about a person who can’t easily share information about themselves. For example, it can be used to record:

  • a person’s cultural and family background
  • important events, people and places from their life
  • their preferences and routines.

The Dementia annual review is a further opportunity to focus on the individual’s current health and social concerns and ensure that the right post-diagnostic support is in place to meet their needs. HCPs are encouraged, as part of their preparation for the CSP consultation, to see if one has been completed and use it to familiarise themselves with the patient.

Utilising a personalised care and support planning approach at the dementia review makes the consultation meaningful for each individual; it helps identify the right care and support for that person and as a result can improve the overall experience of their care.

The toolkit offered here is based on the Year of Care approach to care and support planning (CSP) which has been widely implemented in primary care for a range of long-term conditions including diabetes, respiratory disease and heart disease. The toolkit is suitable for use with other personalised approaches such as Esther.

The toolkit was developed to support the inclusion of dementia within a personalised process ensuring both that people living with dementia felt able to talk about the issues that are important to them and to support professionals to feel more confident in supporting and developing a plan to include the issues that matter to people.

On completion of the consultation, a personalised care and support plan is co-developed to summarise the concerns and resulting actions that were discussed. This would also be an opportunity to update the individuals “This is me” document where appropriate.

Personalised review process

This digital toolkit was developed with input from practitioners, carers and people with dementia by the South East Clinical Delivery and Networks (SECDN). All documents and leaflets are within a single PDF toolkit resource that can be readily downloaded to any desktop, clinical intranet etc and can support any practitioner e.g. GP, practice nurse or dementia advisor.

This toolkit contains the following appendices as separate downloads:

Appendix A: Flow Chart Guide: How to use the Care and Support Planning Approach & Toolkit in a dementia annual review

Appendix B: Example of a completed care plan

Published: October 2020