Aim: Australia’s aging population underscores the need for effective post-diagnostic dementia care, as timely support can improve quality of life, reduce carer burden, and delay functional decline. Yet, gaps persist in service access. The Australian Dementia Network (ADNeT) Clinical Quality Registry (CQR) was established to monitor and improve dementia care. Registry data from Flinders Medical Centre (FMC) Memory and Aged Care clinics revealed low referral rates (26%) for post-diagnostic support provided by Dementia Australia, limiting access to crucial services. This quality improvement initiative aimed to enhance referrals by integrating a nurse practitioner-led follow-up clinic.
Method: A 6-month intervention embedded a weekly nurse practitioner-led clinic, conducting structured post-diagnosis phone consultations with patients and families. These follow-ups completed ADNeT CQR data collection, assessed unmet support needs, and facilitated real-time online referrals to Dementia Australia.
Results: Of 53 newly diagnosed patients, 70% (n=37) accepted an online referral, improving access to support. The remaining 30% received information on how to self-initiate contact. This intervention resulted in a noticeable increase in referral rates, improving post-diagnostic support access for patients of the participating Memory and Aged Care clinics, demonstrating the feasibility of a nurse-led intervention in improving care pathways.
Conclusion: This project shows how registry data can drive targeted quality improvements in dementia care. Embedding geriatrics-skilled nurses in Memory and Aged Care clinics may enhance structured follow-up and referral pathways, ensuring more individuals receive timely support. This model could be up-scaled and tested in more rigours studies to further optimise dementia care outcomes.