Main duties and responsibilities Maintain and regularly update a register of all patients with dementia in the PCN. Complete and review personalised care plans annually for all registered patients with dementia. Establish a robust referral and follow-up system with local memory services and dementia support organisations. Organise monthly multi-agency meetings to review complex dementia cases, to include: Practice Dementia Leads and Administrator, Alzheimer Link workers, Admiral Nurses, Carer Support Practitioner - Council, Memory Service - SATH, Shropshire Council Adult Social Care.
Complete and document carer assessments with appropriate follow-up and support. Conduct annual patient and carer satisfaction surveys to guide service improvements. Deliver community engagement events or awareness sessions (e.g., Dementia Friends sessions, Dementia Action Week activities). Collect and report data to support the PCN's quality improvement objectives, including metrics or unplanned admissions and delayed discharges.
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