Needs Based Assessment Program

In 2016, the Australian Government Department of Health announced the creation of 35 Special Dementia Care Programs (SDCP) in each of the 31 Primary Health Network regions, nationally.

SDCPs are designed to provide specialist accommodation, management and support for PWD who are unable to be effectively cared for by mainstream aged care services due to the severity of their BPSD or Responsive Behaviours. The program will offer specialised, transitional residential support, focusing on reducing or stabilising symptoms over time, with the aim of enabling people to return to less intensive care settings.

SDCP Objectives

  • Provide care for people with dementia whose lives are impacted by very severe behavioural and psychological symptoms of dementia (BPSD) who are unable to be effectively cared for by mainstream aged care services

  • Enable residential aged care providers to deliver care in a dedicated dementia friendly environment (generally a dedicated unit within a broader residential care service)

  • Provide intensive, specialised residential care with a focus on stabilising and reducing the person’s symptoms over time with the aim of enabling transition to a less intensive care setting

  • Complement the existing Australian Government-funded Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Teams (SBRTs)

  • Enhance the existing health and aged care service systems for people with very severe BPSD, including complementing state and territory government services and supports

  • Generate evidence on best practice care for people exhibiting very severe BPSD that can be adapted for use in mainstream settings to benefit all people with dementia

Learn more here.

 

Needs Based Assessment Eligibility Pathway

 

There are strict eligibility criteria for assessment:

  1. The behaviours are primarily as a result of dementia, defined as a progressive neurodegenerative disease
  2. That the behaviours are severe to very severe
  3. That the behaviours have proved intractable to adequate trials of management

 There are 3 phases to determining eligibility, as outlined below. 

 

Phase 1: Making a referral

  • To be eligible for possible placement, the person with dementia must have an ACAT assessment (such that the care recipient is approved to receive residential care under the Aged Care Act 1997)
  • There must be evidence of a dementia diagnosis
  • The person with dementia cannot be under a state or territory mental health detention order when entering a specialist dementia care unit
  • Finally and most importantly, to facilitate the assessment there must be appropriate consent, either from the potential client or their nominated representative

Phase 2: Triage

During triage, the consultant will explore with the current circumstances to better understand pattern(s) of behaviour, what’s happened, what’s changed, any incidents, and timeframes. This will include clinical history, including whether the person’s dementia is the major cause of their behaviours (or whether they may be related to another medical condition, co-morbidity, or disability), whether the person is medically stable and is not requiring treatment that would be more appropriately delivered in an acute care or other health care setting (for example treatment for delirium or terminal agitation) and the severity of the behaviours impacting on their care.

The consultant will undertake an initial risk assessment with the referrer to determine the risk that the person presents to themselves and others within their current environment. The referrer will also be asked to provide information in regards to the extent to which prior behaviour management strategies (recommended by DBMAS and/or SBRT or other dementia support services) have been implemented within their current care setting, and corresponding outcomes. 

Finally, the referrer and the consultant will consider the likelihood that the person would benefit from care in a specialist dementia care unit and be able to transition back to a less intensive care setting within 6–12 months.

This assessment will build on prior DBMAS/SBRT and/or ACAT assessment(s), and other relevant records.

Phase 3: On site assessment

Once a referrer has been successfully triaged and proceeded to assessment for eligbility, the consultant will make a time to conduct an on site assessment. The purpose of this is to validate and build on information provided on triage. This will require access to a range of medical records and other relevant information, and an opportunity to assess the person and their current care environment in more detail, using the DSA validated assessment tool. A medical specialist will review all assessments before outcomes are made. 

A report detailing the results of the assessment will be provided to the referrer. If the person with dementia is found to be eligible for possible Specialist Dementia Care Placement, the relevant Clinical Advisory Committee for the SDCP will be notified of the outcome and be provided with the report. If the person with dementia is not eligible for SDCP, they will be offered ongoing Severe Behaviour Response Team (SBRT) support or other relevant services. If they are eligible they will be waitlisted for assessment for placement by the relevant SDCP. 

Please note: referrals are only open for the North Perth Primary Health Network as part of the Brightwater Specialist Dementia Care Program Prototype. The Department of Health will advise when referrals are open in your area.