Self-management facilitator service
In February 2023 Derbyshire Community Health Services started piloting an innovative new ‘self-management facilitator’ service in Derby. The self-management facilitation team, known as the SMFs, is a team of specialist nurses and nursing assistants who are highly trained in advanced communication skills, clinical procedures, teaching techniques and behavioural change models.
The aim of the pilot is to provide support to self-care at home and increase independence for many people receiving care and also to embed a cultural shift in how patients and staff consider self-care as an appropriate alternative option. Working together, the team supports patients to overcome any worries and identify the best ways of empowering themselves to self-care where possible, helping them to develop the knowledge and skills to self-care at home. Patients are more involved in their own care and this allows health services to continue to provide the most suitable level of care to those who need it most.
The SMFs can support people to self-care at home with:
- Self-injection technique (e.g. enoxaparin)
- Insulin administration
- Catheter care (including leg bags)
- Catheter valve care and education
- Simple wound management
- Compression stocking application.
How has the service helped?
- 74% of all patients seen by the SMF team have been discharged to manage their own condition independently (or with agreed support)
- Derby city core nursing teams have seen a 10% reduction in referrals since the introduction of the SMF service
- Historically, patients requiring insulin injections would remain on the core caseload for a significant length of time (often requiring twice daily visits). With the SMF team intervention, the team are able to support the patients to self-care and discharge them from the caseload to successfully manage their condition themselves. On average, core teams would visit a diabetic patient 60 times per month, but with the SMT visits, diabetic patients are typically discharged after only seven visits, representing a significant improvement in patient outcomes.
The patients have been overwhelmingly positive about their experience with the SMF team, highlighting the positive impact of this service:
- “They involved me in every decision made, and they spoke to me rather than about me.”
- “They have listened to my concerns and reassured me.”
- “I feel very confident to manage my situation now.”
- “I can now inject myself without having to rely on others to come round every day to administer it.”
Since the introduction of the pilot scheme, it has proved successful in releasing vital capacity back into our Derby city community nursing team with the aim to scale-up the service across Derbyshire in the future.