Locality Services Navigators
Linking patients/service users to
community services as part of
Integrated Care
What its about
Improvement of care for people with LTCs,
specifically ……
• “Increasing opportunities for self management by closer and
systematic engagement with local non-traditional providers”
• “Integrated pathways between medical and social models of
health for people with long term conditions”
With additional
• Increased availability of NTPs
• Wider insight on population, needs and trends
Some new terminology
• Non Traditional
Providers
• Petunias
• Navigators
• ‘Social
Prescription’
• ‘Wellbeing
Prescription’
Operational Concept & Framework
Non Traditional Providers?
Third Sector Providers
• Befriending
• Specialist advice
Navigators
Support Group
• Cancer
• Dementia
• MS
Onward
referrals
Organised Volunteering
Neighbourhood Resources
• Library
Faith Groups
• Fire Service
• Parks
Circles Groups
• 50+ membership groups
Leisure Facilities
• Sports & Fitness
• Arts
Clubs/Activity Centres
• Day Centres
• Community Activities
• Self run Interest groups
Organisation Groups
• Circles
• Rotary/WI
Local Businesses
• Cafes for socialising
• Local Shop Access Points
Practicalities
• 2 full time posts
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•
1 North/East.
1 South/Central
• Navigators can work across risk tiers, but with
focus on tiers 2 and 3
• Referrals from MDT, locality administrators, general
patient lists
• To maximise capacity and ensure service response
times on pathway, navigators
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will link to Age UK Community Enablement as appropriate for ‘case work’
and check back
will link to Advice and utilise Market Place services and systems for
encouraging self sourcing of wider help and support
Will access directory of NTPs developed, maintained, provisioned by AUKI
Single – user/patient centric - system view of inputs
and outcomes, across pathway
Core WellBeing Outcomes
Current Outcomes framework and monitoring
Outcomes Development
We are currently looking at ways to incorporate Patient Activation
methodology and metrics into assessment, goal planning and
outcomes processes.
CURRENT/BASELINE
Date:
@ week number 0
(explore with user) - Circle the current ability level.
Use space below for notes to
expand on and give basis for score.
Once finalized enter the score
and these notes into the CL Outcomes grid.
1= not able at all
1
2
5 = completely able
3
1= not able at all
1
2
4
5
5 = completely able
3
4
5
TARGET/GOAL
ENABLEMENT PLAN
Bullet point the things that need to be done to enable the
client to get from their current level of ability to their
target level of ability
>>>>>>>>>>>>>>>>>
These could be things done immediately or, for, the
volunteer mentor to work to.
Looking after myself
Ability to do things like getting dressed, keep clean
how I like, eat well, keep active and feel OK.
Managing my Home
Ability to look after practical things at home. Keeping
it clean /how I like, dealing with bills, small repairs etc
Date:
@ week number 6
(explore with user) - Circle the level of ability the
user would like to reach.
Use space below for notes
Once finalized enter the score
and these notes into the CL Outcomes Target grid
1= not able at all
1
2
1= not able at all
1
2
5 = completely able
3
4
5
5 = completely able
3
Current Outcomes framework
and monitoring
4
5
Development
of assessment
tools and
algorithms to
translate into
confidence/m
otivation
scores as part
of Activation
approach to
measuring
outcomes and
guiding choice
of service
input
The 13 Items & The Stages of Activation
1
2
3
4
5
6
7
8
9
10
11
12
13
Enabling/Self Management Approach
Case Examples of experience with complex cases, involving high levels of liaison
Mrs A
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Female, 79 years of Age, COPD and lung tumour,
highly intelligent and independent, refuses care
and hospital admissions when needed
Heavy smoker and drinker, no motivation to quit
habits despite understanding of impact on
health
Lives alone, small social support network
Refuses hospital treatment during bad times,
takes extra resources from community nursing
Age UK Input
Supported to employ a personal assistant for
housework and shopping- Interviewed and
chose own worker
Age UK Islington are a named contingency
where additional support can be purchased
when needed
Support to apply for attendance allowance to
pay for care was originally reluctant but
motivated to apply for this to meet needs
Provided with regular check in calls
Mrs B
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Female, 64 years old, lives with 3 adolescent sons with mental
health needs, out of control diabetes, long term depression
and poor body image self esteem, very overweight that effects
her ability to walk
No idea what foods she can and cannot eat to control diabetes
or portion sizes
Feels unworthy of support and attention, has been under I
cope for depression
Finds it hard to relate to and express herself honestly with
other professionals, feels judged and ashamed of her situation
Age UK Input
Support to get information on suitable foods to help control
her diabetes from diabetes team
Linked in with diabetic specialist nurse, for further discussion
about her needs
Longer term mentor to help her with devising a new shopping
list and trying news foods to help with her diabetes
Longer term mentor to go out with and build up self
confidence and get some light exercise
Support to apply for a taxi card so she can get out to places
further afield
Regular liaison with her psychologist to ensure joint working
Questions
•
What navigation roles do you currently have?
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How would you like the navigation system to work to support
your organisations?
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How can you help us further support and develop the navigator
role?