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Podcast favourite and Practice Manager extraordinaire Sheinaz Stansfield is back to share more innovation and inspiration from Oxford Terrace and Rawling Road Medical Group – namely, the introduction of a frailty nurse to manage their large cohort of patients with long-term conditions and complex needs. Sheinaz outlines why the role was designed, the impact on the GPs and the wider network, how the frailty nurse works alongside the care navigators (and their wider complex care team) and most importantly, why patients love their new model of care.

Introductions (0:34)

The reasons for change (1:19)

Cultural challenges (2:20)

The creation of the frailty nurse role (3:52)

Population health management / the importance of soft intelligence and hard data (5:17)

How was the new role embedded and what was the initial effect? (6:11)

Impact on practice-wide home visiting (6:55)

How is the nurse supported, day to day? (7:30)

The team around the nurse (8:10)

How does the referral process work? What is the demand? (9:10)

The care navigators (9 mins 55 secs9:55)

When a patient’s condition worsens (10:32)

The benefits to the GPs (11:26)

Whole system impact (12:16)

Is there a danger of being a victim of your own success? (12:48)

Extending best practice across the PCN (14:18)

Is there room for negotiation within the role reimbursement scheme? (14:51)

The effect on internal and wider relationships (15:35)

Patient feedback (16:21)

Future plans? (17:23)

Getting in touch and finding out more (18:40)

APP FORM – Nursing Team of the Year290515_1

Managing Frailty in the Community Submitted

Case Study: Introduction of the Frailty Nurse
https://www.emishealth.com/insights/latest-articles/frailty-care-home-is-where-the-health-is/
https://pcc-cic.org.uk/article/frailty-nurse-halts-rise-unplanned-admissions

Case Study: Introduction of the Care Navigator
http://napc.co.uk/wp-content/uploads/2017/09/PCN_Case_Study_Report.pdf
https://www.england.nhs.uk/atlas_case_study/improving-dementia-care-through-care-navigation-and-social-prescribing/

Oxford Terrace and Rawling Road Medical Group website
http://www.otmg.co.uk/

Twitter: @sheinazs