Improving Access with Primary Care Navigators for dementia, Oxford Terrace and Rawling Road Medical Group Gateshead

Case study summary

The navigators provide some direct support to patients and carers themselves, through regular fortnightly contact via telephone or a home visit, open invitations to the surgery for a “catch up and cuppa” and regular “getting to know you” events to meet with other people in similar situations.

 

Healthcare assistants have received training to spend half of their time acting as navigators, helping to connect vulnerable patients with care and support in the community, and providing direct non-medical support.

Two of the practices’ healthcare assistants received online training and peer support to help understand dementia and ways of providing non-medical support to people with dementia and their carers. They receive referrals from other members of the practice, and, in their other role as healthcare assistants, identify patients themselves would benefit from additional input.

For each new patient, they spend time getting to know the patient and their carers, identifying unmet needs and connecting them with sources of support. Common issues include social isolation and inactivity, and the navigators have built an extensive knowledge of the voluntary and community groups that can help. The navigators also act as a first port of call for nursing homes, handling issues such as prescription requests, visit requests and post-discharge coordination of services.

The navigators provide some direct support to patients and carers themselves, through regular fortnightly contact via telephone or a home visit, open invitations to the surgery for a “catch up and cuppa” and regular “getting to know you” events to meet  with other people in similar situations.

Impact

An evaluation by Deloitte reported that, in the first three months the navigators supported the GPs at the practice with screening 117 patients for dementia, agreeing 396 care plans with patients and connecting 43 carers and 20 veterans with local services. They undertook post-discharge support, coordination of services and medication for 86 patients, removing the need for GP appointment. Hospital admissions fell, by as much as 80%, for patients in contact with the navigators.

Tips for adoption

Initial training is important, and the following topics were found to be highly relevant for this role: understanding dementia, communication skills, understanding the carer experience, the Mental Capacity Act.

A variety of helpful e-learning resources is available from organisations including Skills for Health, Skills for Care, the SCIE Gateway, the Dementia Action Alliance and the Guideposts Trust.

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