Practice management: Improving dementia care

This week we share some innovative ideas that helped Sheinaz Stansfield and her practice, Oxford Terrace and Rawling Road Medical Group, improve dementia care through care navigation and social prescribing.

The challenge

Our practice covers around 15,200 patients – a population that 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, mainly because their needs related to social care and wellbeing rather than acute clinical need. In addition, carers were not being identified and therefore not receiving the support they needed. The majority of this work 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. This also resulted in a high level of unplanned admissions.

The solution

Working with the National Association of Primary Care we developed a Primary Care Navigator role to support patients, their families and carers in gaining access to a very fragmented and complicated health and social care system.

There was no additional funding for this post, existing health care assistant and receptionist roles were redesigned to undertake this function. The Primary Care Navigator role is to:

  • Communicate with patients and carers, ask open questions and actively listen;
  • Guide people to all-sector sources of help and support, from the most local to national, and;
  • Support case finding through referrals from clinicians and opportunistic screening in clinics.

This new role enabled specific targeting and fast-tracking of patients, their families and carers to health and wellbeing support. Usually appointments in the practice are time limited and very focused on clinical tasks/interventions.

Some of the benefits of implementing the new role include:

  • wider practice engagement, achieved by introduction of the programme and expectations at practice meetings and multi-disciplinary staff meetings;
  • 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 consultations;
  • working with and supporting the nurse practitioner and frailty nurse;
  • being a core part of co-ordinated care planning and MDT meeting/planning;

Dealing 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 that are being held that might be of interest
  • making contact within three days of discharge from hospital.

The outcomes

The intervention  improved productivity, motivation and morale of staff. The overall dementia screening increased by 117, assessment for dementia increased by 38 and carers register increased by 43. We have also observed a reduction in discharge letters suggesting avoided admissions – from 7-8 a day to 2-3 a week, within first six months. None of the 86 post-discharge calls needed a physician intervention (usually all these calls would have gone to the on-call GP) and were all handled by the new role. 

What’s crucial, the service provided was more efficient, less fragmented and resulted in a more co-ordinated personalised care.

What’s next?

The Primary Care Navigator role has now been extended to support all social prescribing for people with complex care needs in the practice. In addition, this will be the foundation of implementing house of care approach to the management of long term conditions in the practice to support self-care and self-management.

With current financial and demand pressures on general practice we have to move to more integrated care and place the patient at the centre of everything we do. In addition, with growing numbers of patients being diagnosed with dementia, they and their carers will need this type of support as a single point of access.

Sheinaz Stansfield is a practice manager with over 30 years’ experience in the NHS. She initially trained as a nurse and health visitor, and then worked in commissioning at PCT and strategic health authority level, concerned mostly with developing services outside hospital, for example, integrated primary and community services, integrated nursing teams and services in GP practices. She has also worked for a Primary Care Group as a primary care development and commissioning/contracting manager and helped set up clinical commissioning in Gateshead. She is an elected locality manager for Gateshead Clinical Commissioning Group, practice representative on the Gateshead Newcastle CCG Governing Body and the practice manager representative on the RCGP Northern Faculty Board.


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