We recently spoke to Paula Evans, GP Partner at Millfield Surgery and Clinical Director of the South Hambleton and Ryedale (SHAR) Primary Care Network, and care coordinator Gill Barrett, who works across SHAR PCN, to gather insight into how care coordinators can become an integral role across PCNs.
SHaR PCN consists of seven practices, whose population is 10% above the national average for frail and older patients. Due to a lack of care home facilities in this very rural area, many older patients live alone. As a result, Paula described how this has led to delays in identifying health needs and reduced provision of the services to meet them.
The introduction of the electronic frailty index (EFI) however, has enabled practices across SHaR PCN to proactively identify and risk stratify patients who are at risk of certain conditions, including dementia and frailty. Employing a dedicated care coordinator across SHaR PCN, to offer greater local support to patients with a life-limiting condition, meant practices were able to release valuable time for GPs and form strong relationships with other stakeholders e.g. health and social care, voluntary and care home services. Gill played a role in refocusing practices’ existing multi-disciplinary team (MDT)meetings. Using the EFI, acute admissions data, and feedback from the local community, Gill and the MDT are able to identify any patients who may require additional support during the last year of their life.
A range of services were also present during MDT meetings, allowing the MDT and Gill to identify patients whose clinical and social needs appeared to be increasing but may not have been presenting these previously to such services. By engaging effectively with such services in the community, Gill ensures patients have access to local support networks as required.
Following identification of at risk patients at MDT meetings, Gill would then contact these patients, with prioritisation given first to those of immediate concern, to offer such patients 1:1 personalised support. This approach provided clinicians with a holistic, well rounded view of the patient’s circumstances and a support network, to enable additional appropriate inputs to be arranged. Gill would work with each patient to start to develop a baseline care plan, this involved discussing the support available to the patient currently and what future additional support the patient may require to support their long term needs and wishes.
A crucial role of a care coordinator is also to ensure effective communication is maintained between MDT members for each patient, taking a proactive approach to ensure there is no duplication or opportunities missed.
Gill keeps in touch regularly with her patients by email and telephone, and where appropriate, face to face either at the patient’s GP practice or home, ensuring she is easily accessible to patients.
SHaR PCN has a data sharing agreement in place, enabling Gill to have full access to relevant patient clinical information. This allows Gill to work closely with the clinical leads to ensure the work she does is visible and to measure progress.
“This is the most interesting and satisfying job I’ve ever done. I was motivated to take on this role, because I wanted to help individuals and families impacted by a life-limiting condition based on my own personal family experience. I’m lucky to be part of a great team that wants to make a positive difference to people’s lives. I can help by being accessible and having time to listen. Sometimes just knowing you can call someone who understands your circumstances and talk through a problem is the solution.”