HSE Enhanced Community Care Programme launches new Model of Care for Dementia in Ireland

  • Setting out care pathways for people living with dementia
  • People with dementia centre of care practices

Today (Wednesday, 31st May 2023), the HSE Enhanced Community Care Programme launched a new Model of Care for Dementia to set out care pathways to ensure people living with dementia are at the centre of care practices and service design.

With over 64,000 people currently living with dementia in Ireland, it is a life changing condition. This Model of Care provides an integrated framework to bring together a wide range of services for people living with Dementia and is under pinned by the following:

  • people living with dementia are at the centre of considerations relating to service design and recommendations related to care practices
  • they receive timely and equitable access to assessment, diagnosis and post-diagnostic support regardless of the location of a service, the type of dementia they have, their age, their ethnicity, any other disability or co-morbidity, or their gender.

Launching the Model of Care, Mary Butler, Minister of State for Mental Health and Older Persons, said: “This Model of Care underpins our values of placing people living with dementia at the centre of all considerations relating to their health and wellbeing. It is an innovative approach which ensures that people can be supported within their own communities. There has been a real dementia culture change in Ireland. People know more about dementia and we see communities coming together to include and support people with dementia. With the Model of Care, the emphasis is also on community integration of a wide range of post-diagnostic support services, not only for the person with dementia but also their families, carers and supporters.”

Dr Sean O’ Dowd, Consultant Neurologist, Clinical Lead, National Dementia Office, HSE, said: “As a clinician, it gives me great pleasure to be part of the launch for the Dementia Model of Care. We are all aware of the growing prevalence of dementia in Ireland, so the delivery of this document is timely. The Dementia Model of Care will provide an integrated framework to bring together a wide range of services into a coherent pathway for people living with dementia. There is no doubt that the Model of Care for Dementia in Ireland is an ambitious document that seeks to place Ireland to the fore internationally in our approach to brain health, cognitive impairment and dementia. With this Model of Care and its associated service developments, it means that the people of Ireland will have timely access to exemplar memory services that will deliver best practice in assessment, communicating a diagnosis, personalised care planning and post-diagnostic supports.”

The Dementia Model of Care builds upon the work of the National Dementia Strategy (2014), the HSE Corporate Plan 2021-2024 and has been developed within the context of Sláintecare (2020–2023) and the health reform agenda, where delivering the right care, in the right place, at the right time, given by the right team. 

Dr Colm Henry, Chief Clinical Officer (CCO), HSE, said: “The Model of Care for Dementia provides a clear pathway for people with dementia and their carers. It will enable the person living with dementia greater accessibility to services, have a streamlined pathway of care from initial concerns of memory loss right through to diagnosis, and post-diagnostic supports, while all the time keeping the person with dementia at the centre of everything. The Model of Care also sets out supports for family carers and supporters, who are critical in supporting people living with dementia.”

The Dementia Model of Care provides for a diagnostic model utilising three levels of assessment:

  • Level 1Primary Care GP delivered assessment is considered Level 1, this may include support and information from any of the Enhanced Community Care (ECC) programme services; CHN/Primary Care Teams, Community Specialist Teams for older people, Community Specialist Teams for chronic disease and Community Intervention Teams (CIT).  The decision on appropriateness of referral to Memory Assessment and Support Service, Regional Specialist Memory Clinic or the National Intellectual Disability Memory Service is at the discretion of the primary care physician.
  • Level 2:  Memory Assessment and Support Service: People 65 years or over with a typical and clear presentation of dementia will predominantly be assessed and supported in a Level 2 Memory Assessment and Support Service (MASS) (or/other specialist service).  If a diagnosis is communicated, the person with dementia will be offered relevant post diagnostic supports in their geographical area.  As of May 2023; nine MASS’s have been funded to date, located in the Donegal, Sligo, Cavan/Monaghan, Mullingar, Limerick, Kerry, Cork, Wexford and Waterford.  Funding for additional MASS sites will be sought in future NSP estimates bids.
  • Level 3:  Regional Specialist Memory Clinic (RSMC): People 65 years or under with a suspected dementia or those with atypical or unclear presentations that require a more detailed assessment will predominantly be assessed and supported in a Level 3: Regional Specialist Memory Clinic (RSMC).  However, they may utilise the post diagnostic support services that are local to where the person with dementia lives.  As of April 2023; four RSMC’s have been funded to date, they are located in the Mercy University Hospital, Cork, Galway University Hospital, Tallaght University Hospital and St James’s Hospital, Dublin.

Janette Dwyer, Assistant National Director, Services for Older People, Change and Innovation, HSE, added:  “I am delighted to be part of the launch of the Model of Care here today. Dementia is a life-changing condition that requires responses to support the person across the illness trajectory. Significant work has been undertaken over the past number of years to finalise this Model for Care. The model presents a range of targets and practice recommendations to advance the treatment, care and support for the thousands of people living with dementia in Ireland.

“The Dementia Model of Care is the culmination of significant engagement, investment and collaboration of a broad range of expert stakeholders across community and acute HSE services, voluntary services, Third Level education sector, clinical and executive leadership within the HSE and the Department of Health. The HSE will continue to work closely with new and existing partners to continuously enhance the lives of people with dementia, their families and other supporters.”

It is estimated that for every one person with dementia, there are three others supporting those living with the condition and providing care. The Dementia Model of Care outlines pathways of care that promote autonomy, timeliness, outcome-focused, person-centred and citizenship approaches for people living with dementia; the care pathways will also be enablers for family carers / supporters also. 

Living with Dementia, Charlie Drake, explained: “As a person living with dementia I welcome this Model of Care launch today. The Model of Care is based on the principals of citizenship and personhood and it will put the person with dementia at the centre as they live and journey on their road with dementia. It will give us a voice and a say in how we would like our dementia to be managed. I am very much convinced as a person diagnosed with dementia since 2019 that The Model of Care for Dementia launch today can and will be a huge success and will have a major impact on the everyday life of people with dementia and of course the family carers.  

“There has been lot of thought, planning, time and cooperation with all the different bodies involved with dementia, to bring this Model of Care launch to fruition. A timely diagnosis offers the person with dementia time to plan for the future, and give us access to specialist services and supports.”

Helen Rochford Brennan, Vice Chairperson of the Irish Dementia Working Group, added: “I am so grateful that I was able to be part of this great work.  I have been a member of the Advisory and Consultant Group for the Model of Care for Dementia and we have all worked extremely hard to ensure that this Model of Care will support the person living with Dementia and their Family/Supporters.  I welcome this launch and so glad this day is finally here.”

A strong emphasis is being place on community integration of post-diagnostic support services, not only for the person with dementia but also their carers. Services such as the ASI and Dementia Advisors, and agencies such as Care Alliance and Family Carers, Ireland directly support carers and will be listed as Post Diagnostic Support options on a memory assessment clinical pathway that is currently being developed. 

For more information on the new Dementia Model of Care, visit here.

Last updated on: 31 / 05 / 2023