EVERY ADULT MATTERS

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EVERY ADULT MATTERS

• CARE NAVIGATION
• THE DEMENTIA PROJECT
• Margaret Kitching
• Director of Professions

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CARE NAVIGATION

• What have we been doing?
• Why did we want to do this?
• How have we been doing it?
• Next Steps

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Care Navigation What is it?

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Care Navigation

• Supports/directs an individual through a number
  of services and resources that will help them to
  remain in control of their health and care needs

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Core Functions

• Information/support/advice
• Advocacy
• Organisation
• Integrative care

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Social Care
Psychiatrists
Memory Team Diagnosis Treatment
Voluntary sector
Psychology
Individual Budgets
Allied Health Professionals
Other Providers
Physicians
CMHT
Other Service Providers
Information
Care Navigator
LIFES JOURNEY
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Care Navigation Why?

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WHY?

• Personalisation
• Empowerment
• Self Care
• Self Directed Support
• Choice and Control

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WHY?

• Complex Systems and Processes
• e.g. Crisis resolution
• Assertive Outreach
• Early Intervention
• Memory Team
• CMHT
• IAPT
• Confusion

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WHY?

• Information
• Advice
• Support
• Help

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HOW?

• Engagement
• Engagement
• Engagement

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Barnsley Model

• Two Care Navigators (Pilot)
• Based in Primary Care
• Direct access for existing service users/carers
  from within memory services
• Direct access from within Primary Care
• Championing the CONCEPT of Care Navigation
• Action Learning

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Barnsley Model

• Initial contact predominantly telephonic
• Service users/carers make their choices in
  relation to involvement
• Advice and support where necessary
• Face to face contact where requested or required

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Organisational Development

• Study Day on SDS
• Sessions with Practice and Attached Staff
• Intensive Training/Coaching/Support of CN
• Action Learning Sets for project team
• Scoping of existing available courses
• Today!

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INITIAL OUTCOMES

• 195 Patients accessing care navigation
• Reduction in demand on Memory Team
• Reduction in inappropriate referrals
• Access to a wide range of support
• Crisis Avoidance

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NEXT STEPS

• Evaluation
• Roll Out by March 2009
• Condition
• Practice
• Assess Existing Roles
• Commission an IT Solution
• Commission NWW for CN

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Aspirational Model

• Improved information to aid self direction and
  self care - Barnsley IT Navigation system
• Single point of access - Telephonic Care
  Navigation Hub
• Supported by an IT platform
• Care Navigation in all GP practices
• Culture change across all professions - Self
  Care/Self Directed support embedded in practice

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Personal Stories !

• its much better now having a care navigator,
  it takes a huge weight off me knowing someone is
  there

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Carers Views

• they provide the personal touch, . seeing
  whats going on
• and giving us options

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Patient/Carers Views !

• I didnt know where to start, having a care
  navigator has really taken the pressure off, they
  have connected people to ensure that what I
  needed and wanted happened

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Personal Story !

• we couldnt have done it on our own,we have
  peace of mind

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ANY QUESTIONSMargaret.Kitching_at_barnsleypct.nhs
.ukwww.barnsleypct.nhs.uk/everyadultmatters

• THANK YOU