Sydney North Health Network

Better journeys for people with dementia in North Sydney

A collaboration between the Northern Sydney Primary Health Network (NSPHN), Northern Sydney Local Health District (NSLHD), Alzheimer’s Australia NSW and Community Care Northern Beaches (CCNB)  and a consumer representative was formed in 2015.

The collaboration was formed with support from the NSW Agency for Clinical Innovation’s (ACI) Building Partnerships initiative, and aims to strengthen access and navigation of dementia services. While a wide range of dementia services exist in northern Sydney, information is difficult to find and access to services can be confusing for both consumers and healthcare professionals.

In the early stages of the project, diagnostic and gap analysis activities were undertaken to identify areas of improvement. Local services were mapped by conducting three focus groups comprised of subject matter experts, including local geriatrician Professor Susan Kurrle, as well as community members and health professionals.

One of the key recommendations was to improve the transfer of care and communication for people with dementia leaving hospital. Limitations in information sharing between the acute and primary care settings were negatively affecting the patient’s health outcomes, particularly after hours. The NSPHN commissioned a new service, the first of its kind: a Hospital Discharge Referral Service. It was designed to support people with dementia after leaving hospital and consequently reduce the likelihood of re-admission and impact on after hours ‘crisis’ presentations. Two local providers were commissioned to provide the Hospital Discharge Referral Service across the region: Kincare and Just Better Care (JBC). JBC, working with public and private hospitals in the Hornsby local government area, has implemented the Stay at Home program. Kincare’s Remember Me program covers Ryde, Royal North Shore, Mona Vale, Manly and private hospitals.

Both programs have delivered strong results: each patient referred to the program has progressed well with the support of their general practitioner (GP) and other services, with no further re-admission to hospital.

The collective expertise of the partnership also enabled the creation of the Memory Problems information booklet for consumers and health professionals. The booklet features educational information such as the stages of dementia and what to expect; local support groups; services to help at home for both the person with dementia and their carer; financial advice; legal matters; advance care planning; and palliative care services.

Another focus of the partnership is to better support and build capacity in general practice as GPs play an integral role in a patient’s timely diagnosis and ongoing management. Research shows that it usually takes an average of three years to formally diagnose dementia. To reduce timeframes for diagnosis, the collaborative is currently working with the Improvement Foundation on a set of dementia quality indicators. These indicators will support best practice in early detection, diagnosis and management of dementia in primary care, and will be used to create a national quality program for dementia management.

Following recommendations, the NSPHN has commissioned a GP referred social work service across the region for patients with chronic and/or complex health conditions. The service allows patients’ social needs to be addressed, as these may be adversely affecting their health outcomes.

The NSPHN is also building its first online diagnostic and management support tool – HealthPathways. Designed for GPs and primary care providers, the Dementia HealthPathway will provide clinical and local services information about the condition.

So far the Dementia Better Journeys collaborative has created real change for people living with dementia, and their families. Through providing practical and sustainable solutions, the collaborative has successfully provided better access to care and prevented re-admissions to hospital for people with dementia, which will continue into the future.


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