The Atlas of Shared Learning

Case study

Improving dementia care through care navigation and social prescribing

Leading change

Practice nurses at Oxford Terrace and Rawling Road medical group in Gateshead played a pivotal role in setting up an innovative Primary Care navigator role to help support the needs of patients and carers living with dementia.

This is new way of working, in which healthcare assistants (HCAs) are leading changes in practice to deliver a range of positive outcomes for both patients and carers, including increased access to health and social care services, improved dementia screening, individualised care plans and social prescribing.

Where to look

The Gateshead practice serves about 15,000 patients in a largely deprived urban area. Both nurses and GPs realised they needed a new approach to deal with the pressures they were facing, particularly for the growing numbers of patients with dementia. Nationally there is unwarranted variation in the services and outcomes for people with dementia. At this practice there was a higher than average level of unplanned hospital admissions, associated with the complexity of patient conditions in the local area.

What to change

With more people receiving a dementia diagnosis, senior nurses and GPs began to seek an alternative approach to the conventional ten-minute appointments. Many of these patients’ needs related to social care and wellbeing rather than acute clinical issues. Carers weren’t being identified and appropriate support wasn’t being received. Most case finding was undertaken by GPs and senior nurses. Some patients and carers were becoming frustrated, and the quality of care was at risk of being compromised.

Nurses and colleagues decided to develop a bespoke practice-based model by redesigning roles and developing new skills.

How to change

Working with the National Association of Primary Care, the practice manager and her team developed a Primary Care navigator role – targeted to support dementia patients, their families and carers. The aim was to improve their access to the health and social care system, including signposting to wellbeing services through social rather than clinical prescribing.

This was a new departure in General Practice, with no additional funding. Existing health care assistant and receptionist roles were redesigned to undertake this function. Staff were trained to prepare them for the change.

The purpose of the Primary Care navigator role is to:

  • Communicate with patients and carers, asking questions and actively listening
  • Guide people to sources of help and support, from the most local to national
  • Support case-finding through clinical referrals and opportunistic screening
  • Develop a directory of services of third sector and other community support available for people with dementia and their carers

Additional patient support includes fortnightly calls or visits, invitations to “catch up” events, contacting support organisations for those who can’t do themselves, and making contact within three days of discharge from hospital.

The practice has now extended the navigator role to support all social prescribing for patients with complex needs. It will be the foundation for implementing a ‘House of Care’ approach to long term conditions, to support self-care and self-management. Gateshead CCG has included the initiative in its primary care strategy.

Adding value

Benefits from the navigator role have included better communication within practice, a single point of contact for care homes, fewer issues with prescription, longer consultations for vulnerable patients, and support for co-ordinated care planning.

  • Better outcomes – Within three months: Dementia screening increased by 117 patients, assessments for dementia by 38, registered carers by 43 and the veterans’ register by 20; 396 care plans and 95 NHS Health Checks were completed. Within sixth months there were fewer hospital discharge letters which indicated a reduction in admissions from 7-8 a day to 2-3 a day.
  • Better experience – Patients now have more coordinated and personalised care. The intervention has improved staff productivity, motivation and morale. At the outset, care assistants and receptionists were worried about a lack of experience in taking on the navigator role. After three months, they reported being confident, valued and positive about their job.
  • Better use of resources – Of 86 post-discharge calls, none required a physician because they were handled by the navigator. Previously, all these calls would have gone to the on-call GP. The training has enhanced the transferable skills of the HCAs undertaking the navigator role and they are now able to provide the same ‘sign-posting’ service to patients with long-term conditions and complex care needs as a part of a personalised care plan approach.

Challenges and lessons learnt for implementation

  • Capacity within practice was a challenge – both to support this type of change, and to release the required staff time.
  • Training has enhanced the transferable skills of the HCAs undertaking the navigator role, including understanding frailty, dementia and social prescribing.
  • Patient’s diagnosed with dementia, and their carers benefited from support available at a single point of access.
  • The navigator service has now been rolled out across 3 other practices in the area.

Watch this film about Primary Care Navigators

Health Care Assistants at Oxford Terrace and Rawling Road Medical Group, Gateshead, discuss their roles as Primary Care Navigators, who advise and support patients and carers with any social needs that may be affecting their health:

Find out more

For more information contact:

Sheinaz Stansfield

Practice Manager