Easy read and translate
Luton Community Matron Specialist Dementia Care Service
The Luton Community Matron Specialist Dementia Care Service is provided by a community matron (physical health), specialist in dementia care. It is not provided by an admiral nurse. People living with dementia (PLWD) experience palliative care needs as their dementia progresses and will require both palliative and end of life care.
Our team focuses on:
- post diagnosis support for PLWD and their families or carers
- planning for future care
- palliative and end of life care
We provide:
- home visits for first contacts, brief interventions and reviews
- healthy lifestyle and health promotion
- telephone advice and signposting
- multi-agency referrals as appropriate
- person-centred (Hospital Admission Avoidance) Care Planning
- Advanced Care Planning including preferences, decisions, advance directives and statements etc.
- education of professionals involved in caring for people living with dementia and their family members or carers
- a single named professional who is responsible for coordinating care for people living with dementia
Our goals:
- Provide comprehensive and holistic nursing, physical, psychological and social assessments.
- Support people living with dementia, their families and their carers.
- Identify carers needs.
- Advise and support in the management of dementia including mood, behavioural and psychological symptoms of dementia (BPSD).
- Undertake medication reviews: Anti-Dementia, Antipsychotic (neuroleptics), Antidepressants, Anxiolytics and Hypnotics.
- Promote person-centred care.
- Coordinate care between services.
- Care planning including hospital admission avoidance and advance care planning.
A period of Intensive Case Management including:
- holistic nursing assessment including communication, cognitive function, behaviour or mood, level of function with activities of daily living (ADLs): eating and drinking; toileting and continence, transferring/moving/walking, nutrition, hydration and weight management
- identification of carers needs
- coordinated care and support between services
- brief interventions
- advance care and support planning
- person centred care
- hospital admission avoidance care planning with a ‘personalised element’
- personal care and support planning including 'anticipatory' and 'personalised' elements
Referrals
We will accept referrals from:
- GPs
- Memory Assessment Service (MAS)
- dementia nurse specialists at the Luton and Dunstable Hospital
- community nurses
- social services
- other healthcare professionals
To refer into the service, call 0333 405 3000 or email CCS-TR.LutonRMSreferrals@nhs.net.
We are currently unable to accept self-referrals.
People living in the community, their family members or carers who are concerned that a patient may be showing the signs of dementia but are, as yet, undiagnosed should be referred to their GP for dementia screening. This will include a collateral story from patient/NoK/carers, a blood test, urine dipstick & MSU if/as indicated to exclude a reversible condition. A referral can made to the (ELFT) Older People’s Community Mental Health Team Memory Assessment Service elft.referrals.lops@nhs.net for a formal assessment and diagnosis
Eligibility
To be eligible for our service you must meet the following criteria:
- Adults 18 years old and over registered with a Luton GP.
- Diagnosed with dementia and living in the community.
- Have a cognitive impairment and no formal diagnosis of dementia living in residential care homes.
- Have a cognitive impairment and no formal diagnosis of dementia under the care of the District Nursing Team.
Contact us
You can contact our service Monday to Friday 8am to 6pm.
Telephone number - 07881 512099 or 0333 405 3000