dementia-care-follow-up-maintenance

Follow-Up & Maintenance Schedule — Dementia Care

Plan follow-up and maintenance so gains for people living with dementia and their families are checked and sustained. The deliverable is a follow-up schedule with intervals, checks and escalation triggers. This skill is written for a dementia care specialist working with people living with dementia and their families in care homes, hospitals and homes.

When to use

• You are a dementia care specialist preparing, delivering or reviewing this part of your work in care homes, hospitals and homes.
• You need a defensible, repeatable approach that produces a follow-up schedule with intervals, checks and escalation triggers.
• A colleague, auditor or client asks how this was done and what evidence supports it.

Key Concepts

Term	Meaning
Life story work	gathering a person's history to personalise care
Capacity	a person's ability to make a specific decision
Reminiscence	using memories and familiar items to support wellbeing

Workflow

1. Step 1 - Set follow-up intervals from the plan and from how distress incident rates is expected to move over time
2. Step 2 - Define what is checked at each contact, using memory aids where measurement is needed, and record it in life story documents
3. Step 3 - Give people living with dementia and their families clear guidance for the interval: what to do, what to watch for, when to make contact sooner
4. Step 4 - Act early on warning signs — deterioration linked to distress misread as behaviour problems shortens the interval, never lengthens it
5. Step 5 - Close the follow-up cycle formally when goals are met, with a summary and re-entry route if needs return

Profession-Specific Components

Component	Details for Dementia Care
Core documentation	life story documents; care plans; behaviour records; capacity assessments
Core tools & equipment	memory aids; reminiscence materials; monitoring technology; recording systems
People involved	people living with dementia and their families; the dementia care specialist; colleagues and other services in care homes, hospitals and homes
Primary record	life story documents — keep it current, dated and attributable

Output Format

Context: [Situation in care homes, hospitals and homes] | Objective: [What this must achieve] | Audience: [people living with dementia and their families and other stakeholders]

The finished output is a follow-up schedule with intervals, checks and escalation triggers, structured as:

1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

Action Plan

1. Immediate: Confirm scope, consent and the evidence available in life story documents.
2. Short-term: Complete the workflow steps and record outcomes against distress incident rates.
3. Medium-term: Review results, close actions, and update local procedures in care homes, hospitals and homes.

Success Metrics

Metric	Target	Method
distress incident rates	Agree a local target and track the trend	Measured from life story documents and reviewed on a set cycle
antipsychotic use monitoring	Agree a local target and track the trend	Measured from life story documents and reviewed on a set cycle
family satisfaction	Agree a local target and track the trend	Measured from life story documents and reviewed on a set cycle
activity participation	Agree a local target and track the trend	Measured from life story documents and reviewed on a set cycle

Guardrails & Quality Checks

• Never let this happen: distress misread as behaviour problems.
• Never let this happen: unsafe wandering.
• Never let this happen: families not involved.
• Work only within the competence and authority of a dementia care specialist; escalate or refer anything beyond it.
• Record facts and observations, not speculation, and keep records confidential to care homes, hospitals and homes's rules.
• Verify names, dates, figures and measurements twice before anything is issued or signed off.
• Use only real, verified information from the case in hand — never invent results, credentials or evidence.

Example (illustrative)

A dementia care specialist in care homes, hospitals and homes applies this workflow for people living with dementia and their families: they open life story documents, work through the five steps using memory aids, and close by recording the outcome against distress incident rates and agreeing the next review date. (Illustrative example only — replace with the real details of the case in hand.)