Oxford Terrace and Rawling Road Medical Group (OTMG-RR) is a GP practice, situated in Central Gateshead. The population of about 15,200 patients is predominantly deprived, with high numbers of refugees and asylum seekers.Our prevalence of patients with dementia is 200%. With growing numbers of patients receiving a dementia diagnosis, it was becoming increasingly challenging to manage their needs through 10 minute GP appointments, predominantly because their needs related to social care and wellbeing rather than acute clinical need. Also, community services were becoming less visible or accessible, and there was fragmentation of the health and wellbeing system due to new contracting and financial pressures. Also, challenges with GP recruitment was increasing pressure on daily demand. The majority of case finding was undertaken by GPs and Senior nurses. The on-call doctor was overwhelmed, patients and carers frustrated, staff were struggling and the quality of care in danger of being compromised. There was a high level of unplanned admissions.
We developed a Primary Care Navigator role to case find and support both patient’s, their families and carers though better navigation through a very fragmented and complicated health and social care system. In addition we needed to sign post these patients and their families to wellbeing services through social rather than clinical prescribing.
Introducing the New Role:
• wider practice engagement, was achieved by introducing the programme and expectations at practice meetings and multi-disciplinary staff meetings. The concept was introduced to patients and carers through a ‘Health Fair’ and by using practice and patient champions to spread the word;
• agreeing individual care plans and accountable GPs
• providing nursing homes with a single Point Of Contact for prescriptions and requests for visits
• supporting doctors and nurses in their interaction with vulnerable patients by enabling them to refer to the PCN for longer consultation
• working with and supporting the nurse practitioner and frailty nurse
• Being a core part of co-ordinated care planning and MDT meeting/planning. Working with patients and their carers involves: • open invitations to the surgery for a “catch up and cuppa”
• “Getting to know You” events
• identifying people’s needs and sign-posting to available help and contacting organisations on their behalf if they have difficulties doing so themselves
• regular fortnightly contact via telephone or a drop in to see how progress is being made and what is still needed
• updates on events and practice linked groups that are being held and might be of interest
• making contact within three days of discharge from hospital.
• Setting up of self help groups around the practice population/need
Outcomes in the first three months
• Dementia Screening increased by 117 patients
• Assessment for Dementia increased by 38 patients
• Carers register increased by 43 patients - all signposted to appropriate support;
• Veterans Register increased by 20 patients - signposted to appropriate support
• Care Plans increased by 396
• NHS Health Checks increased by 95
• 86 patients were contacted post discharge. All were supported through social prescribing rather than clinical support;
• Reduction in discharge letters suggesting avoided admissions recued from 7 to 8 a day to 2-3 a week, within first six months.
• improved communication within the practice and with external organisations
• less fragmentation
• reception managing better
• less prescription errors
• more co-ordinated personalised care
This role is now a core part of our practice complex care team and is being extended to lead on supported self-care as part of our house of care model for the management of long term conditions