User Persona – Social Care Team Leader
Bio
‘I’m a Team Leader for an Integrated Care Coordination team, responsible for managing a group of care coordinators who work closely with adult social care. With over 5 years of experience, my primary focus is on providing support to older adults, ensuring they receive the necessary care before a crisis arises. My team coordinates services like care packages, medical equipment, and community support to prevent hospital readmissions. I oversee the work of the team’s three main referral pathways. We use the Shared Care Record everyday to view patients most up-to-date information to ensure the right path for the patient.’
Quotes
“Finding NHS numbers can be really difficult, and if I can’t find the number, it prevents me from having a sensible conversation with the caller.”
“The biggest frustration is not knowing exactly where patients have been discharged to. We spend time trying to track them down, and if the system just told us clearly, it would save so
much time and effort.”
“I think it’s just peace of mind that you know the patient’s safe if you can’t get hold of them. It’s also very efficient for our line of work with the pathway zeros because it’s telling you straight away that somebody is in a community hospital. You’re not then ringing switchboard and waiting forever how long to get through to somebody – you know it’s there in front of you.”
Goal and motivations
My primary goal is to ensure patients receive the necessary care and support as quickly and efficiently as possible, making sure the right care is in place before a crisis might happen.
- I seek to coordinate care effectively by using the ShCR to gain a comprehensive view of a patient’s medical and social history
- Avoid duplication of efforts, reduce gaps in care, and ensure that care is provided seamlessly across different teams and services
- Make my work processes more efficient and reduce the need for extra steps, such as unnecessary phone calls or manual data entry
Challenges
- Cannot easily find NHS numbers for callers, crucial for completing assessments
- Lack of access to previous addresses, which makes verifying caller identity difficult
- Hospital Admission Information is sometimes unclear causing confusion
- There are gaps in information like patient locations after discharge
- Resistance among some colleagues to using the ShCR some team members require more training
- Unclear terminology of codes and abbreviations
- Sometimes need to make extra phone calls or take additional steps because the info is not there
- Does not consistently identify informal carers or include details about emergency carers’ contingency plans, leading to confusion during emergencies
- Information about patients who are fully CHC funded (Continuing Healthcare) is not readily available in the ShCR, which can affect the level of care a patient is entitled to
- Lack of End-of-Life Status: the system does not readily provide details about whether a patient is at the end-of-life stage, which is essential for determining appropriate care and support
Opportunities
- Improve clarity of terminology for patient discharge locations (e.g., community hospitals vs. residential homes) or include a code crib sheet for each location for people to refer to
- Integrate data from community hospitals into the ShCR
- Display end-of-life, Continuing Healthcare (CHC) funding status and carers’ contingency plans
- Allow easy re-access to patient records without locking users out
- Include detailed discharge letters for every patient transfer
- Enable reverse search for NHS numbers based on name and address
- Make email addresses and phone numbers easier to copy/paste
- Improve visibility of hospital admission information and encounters
- Offer clearer identification of patient safety and current location
- Provide training and promote wider adoption of the ShCR