Delivering enhanced care across the whole system: dementia ‘virtual ward’

Robert is 82 years old living in a care home. He was referred to the care home ward round after his family and care staff noticed among other things, he unusually kept losing track of a conversation and had started repeating questions.  From assessment and discussion on the care home ward round Robert’s GP and Older Persons Nurse Specialist referred him to the Virtual Ward for further assessment by the Old Age Psychiatrist and a subsequent diagnosis of mixed dementia was made along with the introduction of medication [donepezil].

Dementia diagnosis is a detailed process best undertaken out of hospital settings and should be timely to prevent rapid progression of the disease and also to reduce what can be distressing symptoms.


Dementia is a common condition in an ageing population world and making a timely diagnosis is almost as important as making the diagnosis itself.

Early detection and allowing care from integrated teams facilitates understanding of the condition, as well as allowing access to particular drugs and services.  Above all, it lets patients and their families and carers to make plans for the future.

How it works

Our model of enhanced care into care homes enhances early dementia recognition

  • Rapid access to specialist mental health opinion via the Virtual Ward
  • Non-drug interventions for challenging behaviour
  • Integrated teams wrapped around the resident with GP and /or Older Persons Nurse Specialist as care coordinator.

Success so far

While his initial follow up care was with the psychiatrist, once improvements were seen, Robert’s care was successfully transferred back to the GP and Older Persons Nurse Specialist who worked in partnership with the Old Age Psychiatrist regarding longer term care and monitoring.  Thereby allowing the psychiatry team to focus upon those most complex, whose dementia has progressed making meeting needs more challenging, or whose disease is characterised and complicated by delirium.

What has been the financial impact of this innovative idea, compared to before implementation?

This approach sees the patient at the centre of decision making, with services wrapped around them to provide care at their place of residence. We have seen an increase in dementia diagnosis in care home residents as a result of our enhanced care model and an increase in non-drug interventions for challenging behaviour – we have seen a subsequent reduction in the prescription of antipsychotic medication.

Lessons learnt

  • Comprehensive assessment and individualised care planning are key to manage frail older residents in care homes.
  • Timely access to specialist opinion
  • It is important to have consistency in care delivery by appropriately trained staff into the care home setting due to the complex nature of the residents.
  • There is high incidence of dementia in care home residents and it is essential to recognise the close interaction mental and physical health play in order to deliver quality care in this population. Therefore old age psychiatry are a key members of the enhanced care team.

Find out more

Our journey started long before Vanguard and it will continue long after it disappears. Watch this video to find out more about the Newcastle Gateshead CCG care home vanguard: