Kirsty Rolt
Development Support Manager
ESP Primary Care Hub, Southampton
The Challenge
With primary care experiencing increased pressures from both high patient demand and a growing population, the care navigator team funded by the integrated care board had to evolve to meet these demands.
The challenge with any service is to evolve, to align with the changing landscape of primary care. With the formation of primary care networks, the care navigator team started the ball rolling with integrated working alongside the primary care network staff and working as one team. This ensured consistency with the service and a positive change to work collaboratively with multi-disciplinary teams.
“The team, patients and PCN staff continue to benefit from this integrated working approach. Patients now benefit from this additional support have been extremely resilient in embedding this service throughout the locality – championing patients and delivering better joined up working.”
The Innovation
As new staff were recruited under the additional roles scheme, Kirsty and her team maximised the opportunities to work with staff in these roles to develop a team-based approach to care. The project focussed on collaboration by bringing together care navigator teams across primary care networks. They held regular “walk and talk” meetings for teams and documented monthly patient demand to demonstrate increase in caseload over a 6-12 month period.
The team now refer 300-500+ patients monthly, enabling the team to deliver exceptional services that improve patient quality of life and reduce frustrations.
The Impact
- Team: Improved communication and team resilience through integration
- Time saving: Active signposting encouraged and empowered colleagues to refer patients to the correct service, saving time and building patient confidence
- Improving patient journey: Patients had a real understanding of how they could be supported at home and what was available to keep them independent.
