Cumbria Partnership NHS Foundation Trust has introduced new Case Manager roles across South Cumbria Primary Care Communities, including Millom and Duddon Valley, to help support patients with long term health conditions.
Sonya Park currently works part –time as a district nurse in the Millom area and she has taken on the additional role of assisting at risk individuals to self-manage their long term health conditions with the hope that it will prevent unplanned hospital admissions.
Sonya Park said:
“I want to assist people to live the life they want to live the best way they can, by preventing unnecessary hospital admissions and by having the right interventions and support in place in the hope their individual needs can be met at home”.
Depending on an individual’s needs, Sonya spends up to six weeks with each patient supporting them to improve their health and wellbeing. This may be by helping them access a wide range of groups or services available in the local community and assisting them in self-management of their condition.
Sonya Park added:
“I act as an umbrella service over the patient co-ordinating other services including the mental health team, GP’s, district nurses, community nurses, members of the STINT team and the newly appointed Care Navigator”.
Local GP Dr Geoff Jolliffe from Barrow-in-Furness said:
“As a local GP I’m very pleased to see this Case Manager role working in our local community. As part of the Better Care Together plans it’s vital that we see more support offered outside-of-hospital: the vast majority of the people I see don’t want to be in hospital, they want to be in their own home or neighbourhood. To stay healthy and happy at home people with long term conditions such as diabetes, respiratory problems and high blood pressure will really value the support of a case manager like Sonya”.
Sonya will work closely with the district nursing team. Sally Carter, District Nurse in Millom said:
“Within Sonya’s Case Manager Role she will be coming into contact with patients who have nursing needs that may have previously gone undetected and unmet. And in turn her role within District Nursing services will mean that she may foresee gaps in our current service provision and care planning that can be bridged within her Case Manager role in order to prevent hospital admission and promote closer working across all services involved through the use of forward contingency planning”.
Whilst focusing on the individual patients, Sonya will also work closely with the family and carers, GP, clinical interface manager and community paramedic to ensure that care plans reflect the wishes of the patient regarding their care and also their current level of health and health management ability.
Claire Morris, Community Paramedic said:
“I have the opportunity to work collaboratively with Sonya to enhance care plans further and link with the ambulance service to serve the local community better”.
Referrals to the Case Manager are via GP’s.