About the service
Important information about this service
The Barnsley care navigation/ telehealth service that the South West Yorkshire Partnership NHS Foundation Trust provided, through the delivery of telephonic services and telehealth vital sign monitoring to patients with long-term conditions in Barnsley, has now been decommissioned. The Barnsley Clinical Commissioning Group (CCG) made the decision to decommission the service following a review of the service. This resulted in the Trust no longer providing telehealth monitoring and telephonic health coaching services to Barnsley patients from 31 January 2018.
For any patient who may have accessed the service previously and who were enquiring to re-access the service again, then please contact the Barnsley community nursing referral service on 01226 382594 for assistance.
Please note that the South West Yorkshire Partnership NHS Foundation Trust will continue to deliver its Bassetlaw care navigation/telehealth service until 29 June 2018. Following a separate service review the Bassetlaw Clinical Commissioning Group (CCG) has also taken the decision to cease funding the service therefore from 30 June 2018 this service will no longer exist. As patients are often only with the care navigation service for short periods of time, patients who are currently on a Bassetlaw care navigation and telehealth programme will be given the opportunity to complete it. This change will therefore not affect many current service users. For those likely to be affected we will be in contact to discuss the changes.
Why would someone choose the service?
- We help you navigate care and provide support, so you feel more in control of your health condition
- Our team of nurses can help you if you have been newly diagnosed with a long-term health condition. We can also help if you have been living with your condition
- for some time or if you have more than one condition
- We tailor our care to make sure that it suits the individuals and their needs
- We’ll give you information about local services that you may not be aware of – such as self-help groups, support groups, social services and the voluntary sector
- We offer support to achieve existing goals or help in setting new ones
Listed below are the responses received from patients following the 2014 / 2015 audit for those patients that had accessed the care navigation and health coaching pathways:-
Care navigation pathway patient responses:
- 82% said their confidence has increased
- 77% felt that they are more in control of their condition
- 77% had visited the services identified through the care navigation service
- 64% said the care navigation service has helped them solve a problem
- 59% felt the service helped them identify local services which benefited them
- 59% said they are visiting their GP less
Health coaching pathway patient responses:
- 100% identified realistic goals and had taken steps to act on them
- 100% agreed that they felt more in control of their condition
- 100% made lifestyle changes
- 100% agreed that they visit their GP less
- 75% had increased their confidence
- 75% felt their quality of life has improved
Our inspiring stories, featuring Barnsley people who have used our service, show how our service has changed their life: www.takecontrolBarnsley.co.uk
Staff you may meet
- Administrative staff provide essential support to doctors, nurses and other healthcare professionals. This can be in a variety of different settings, with administrators working as a receptionist in a clinic or a clerk on a ward. They may also be working closely with a consultant as a medical secretary.
- A care navigator provides advice and support to individuals their families or carers during their care. They often make home visits and support hospital discharges. Care navigators can also signpost and refer individuals to the appropriate services or help arrange care based on the individual’s needs.
- There are many people who work behind the scenes to keep services running and you may meet them in hospital or community settings. They include porters, cleaners, plumbers, electricians, decorators receptionists and secretaries who all work to make sure healthcare settings are kept clean, tidy and safe.
- Nurses who choose to specialise in the mental health branch of nursing work with GPs, psychiatrists, psychologists, and others, to help care for patients. Increasingly, care is given in the community, with mental health nurses visiting patients and their families at home, in residential centres, in prisons or in specialist clinics or units.
Why a professional should choose the service
- The service was nominated in 2014 for a Nursing Times Award within the category of ‘Care in the Community’
- Evidence undertaken suggests that people accessing the Barnsley care navigation/telehealth service has contributed have reported the following benefits:-
- Increased ability to manage their own condition
- A greater awareness of their particular condition
- Motivated to make positive health impacting behaviours
- The deployment of telehealth technology has assisted in reducing patient anxiety and enabled the potential exacerbation of conditions to be detected earlier and treated accordingly
- They have experienced improved patient quality of life whilst living with a long-term condition
A CCG commissioner of the service undertook analysis in November 2013 to ascertain the impact of the care navigation and telehealth service towards the following service utilisation for those patients that had accessed the service:
- Primary care attendances
- A & E attendances
- Emergency admissions
The analysis focussed on the three elements of service that were delivered; care navigation/health coaching and telehealth vital sign monitoring.
The results of this analysis was extremely positive as there was evidence to suggest that due to the various interventions provided by the service, the utilisation of the above services had significantly reduced.
Primary Care attendances:
- 46.5% reduction of those patients accessing care navigation/health coaching
- 14.6% reduction of those patients accessing telehealth vital sign monitoring
A & E attendances:
- 31% reduction of those patients accessing care navigation/health coaching
- 35% reduction of those patients accessing telehealth vital sign monitoring
- 46% reduction of those patients accessing care navigation/health coaching
- 27% reduction of those patients accessing telehealth vital sign monitoring
- Advice and information relating to appropriate services that may address any care needs that the patient may have
- Telephonic support/assistance regarding motivation in order to facilitate positive behaviour change
- Improved self-care/self-management of long-term conditions
- Signposting/onward referral to appropriate services
- Improved self-management skills
- Improved physical health/mental health
- Improved engagement with appropriate services
Referrals accepted from:
A & E, AHPs, Carers/family, Consultants, GP staff, GPs, Hospital staff, Local authority staff, Other NHS services, Other Trust services, Patients(self-referral), Voluntary services
Care navigation / health coaching referral criteria:-
Those diagnosed with a long-term condition (i.e coronary heart disease (CHD), stroke / transient ischaemic attack (TIA), diabetes, chronic obstructive pulmonary disease (COPD), heart failure, asthma, hypertension, depression) who are:
- Over 18 years
- Registered with GP within the Barnsley borough or resident
- Need more information about their condition in order to become more self-managing
- Need information about local services, self help programmes, financial services, social services etc, to meet their individual needs
- Need help / support in accessing services (advocacy)
- Need regular telephonic support to comply with advice/treatment
- Need help with motivation and confidence
- Have modifiable risk factors (identified using the modifiable risk factor) Stratification tool and the “Barnsley Health Checker” tool) and need help to change behaviour (health coaching element only)
- Have had recent exacerbation requiring hospital admission and meet selection criteria
- Require a supported discharge package
- Require vital signs monitoring
Telehealth monitoring referral criteria:-
Those diagnosed as having severe COPD, heart failure or diabetes who meet one or more of the following criteria:
- Those identified as having 2 or more secondary care admissions in the last 12 months with a primary diagnosis of heart failure, COPD or diabetes
- Those that have had 2 or more exacerbations of their long-term condition within the last 12 months that resulted in primary secondary care intervention
- Those identified as having a history of inappropriate use of emergency ambulance services
- Those who are deemed non-concordant with prescribed treatment or those that require monitoring re medication changes