Hunter New England and Central Coast Primary Health Network

New England Dementia Partnership (February 2017)

The New England Dementia Partnership is a collaboration between three of the leading health organisations in the New England North West region of NSW – HealthWISE New England North West, Hunter New England Local Health District (HNELHD) and the Hunter New England Central Coast Primary Health Network (HNECC PHN). The Partnership began in 2003 and its aim remains to: improve the health outcomes and quality of life for people living with dementia, their carers and families.


With only half of dementia cases currently being diagnosed, reducing the barriers to timely assessment was a major challenge for the partnership. One strategy the group pursued was to identify those clinicians across the region who are able to administer an initial, brief screening tool to determine whether further assessment is required, and the dementia clinicians who are able to support general practitioners and medical specialists by undertaking a comprehensive dementia assessment.

Another achievement has been the creation of a standardised referral form and referral pathway for memory assessment services. This has included an electronic referral which self-populates patient details and clinical information, such as test results into medical software (Medical Director and Best Practice). A clinical case discussion framework has also been developed to provide peer support across clinical settings and ensure reporting back to referring GPs.

Documenting all of the information gathered by the partnership, as well as a suggested suite of validated screening and assessment tools, formed the basis of the New England North West Dementia Care Information booklet for clinicians and health workers. The booklet contains general information about dementia, as well as information specific to the region. The purpose of the document is to assist healthcare providers to recognise, assess, diagnose and manage dementia. An electronic version of the booklet contains links to further information, templates and training opportunities. All of the dementia partnership documents are available for download on the PHN website,

Despite the geographical challenges, the dementia partnership demonstrated that a collaboration between three organisations can form a team whose members are able to work together and make decisions as if they were employed by one organisation – the single, standardised referral and referral pathway are good examples of collaborative work practices. The work undertaken by the partnership has been built into the current roles and work hours of everyone on the team, to ensure a sustainable model beyond the current project. However, the work of the partnership would not have been sustained if it were not for the support of the executive managers of the three partner organisations, and a commitment from the team members to develop a strong working relationship to ensure a solid foundation for future project work.

Planning is underway for 2017. The dementia partnership will continue to ensure dementia clinicians are trained in the use and interpretation of comprehensive dementia assessments, and will review and support the training of those clinical staff who administer brief and initial screening tools. The partnership also plans to provide a recommended suite of resources for those who are newly diagnosed with dementia, and their carers, to ensure consistency of information provided across the region.

The New England Dementia Partnership thanks the NSW Agency for Clinical Innovation (ACI) for seed funding from the Building Partnerships program, which aims to improve care of older people with complex health needs. The partnership also received support from the ACI to develop team skills in planning, diagnostics, solution design and evaluation, which will ensure sustainable program development.


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