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Care Navigation

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Age UK Solihull’s Head of Service, Lucy Garratt, talks about the new Care Navigator pilot project which is running in Solihull until the end of March 2017. 

Care Navigators Oct 2016 croppedSolihull’s first Care Navigators are (from left to right): Alison, Eve, Melanie and Teresa

What are Care Navigators?

Sometimes it’s good to have help working out what kind of care and support you need. That’s where Care Navigators come in. They are based in GP practices and support older people (usually 65 or over) to find and access the services they need to stay well and independent. Care Navigators know about the many health and care services which offer support to older people in the borough. So people and their families don’t have to navigate the system on their own.

You could also think of Care Navigators as another pair of eyes and ears for the GP. When a GP sees someone in the 10-minute consultation they may identify additional issues which can’t be sorted out during the appointment but have a direct impact on the person’s health and wellbeing. Now GPs can now refer these patients, with their consent, to their Care Navigator, so that they can follow up on the concerns and identify the support needed.

Care Navigators can also support people when they come out of hospital. They can be very vulnerable at this time so GPs will be able to give the Care Navigators a list of their patients who have been discharged from hospital. The Care Navigator will give them a call to find out how they are doing. Some people will be coping and need no additional support. But this isn’t the case for everyone so the Care Navigator can visit them the same day to make sure they have something to eat and drink, are warm and understand the medication they have been given by the hospital.

What difference will Care Navigators make to Solihull residents?

I hope they are going to make a big difference. Care Navigators look at the whole picture of someone’s health and wellbeing, what we call a holistic assessment. Wherever possible, they will visit the person in their own home. By having an in- depth conversation with them, they will unpick what’s really going on and what kind of support the person needs.

Together the Care Navigator and the individual create an action plan. This will include actions for the person themselves – it could be doing 5 minutes of exercise during a TV programme ad break - and actions for the Care Navigator, such as finding out about a support group or sourcing small aids or equipment to help keep the person independent.

Within the plan there may also be actions to help people manage their own care into the future. The Care Navigator will help the person to develop the skills and tools to do this. Both sign the action plan. Once all the actions in the plan have been completed, the person is discharged from the Care Navigation service.

People don’t always take advantage of support groups and services that are available locally. That could be because they aren’t aware of them; because they need help to get to the group; or because they feel unsure about joining a group where they don’t know anyone. Care Navigators can help with all of these issues, for example, working out the bus route or taking someone along to a group until they get to know the people involved and feel comfortable.

What difference will Care Navigators make to health and care professionals in Solihull?

Talking to GPs, I know that they have patients who keep coming back to the surgery with the same medical issue but it’s actually underlying factors, such as loneliness or practical issues like their heating or finances which need sorting out. With the Care Navigator in place, the GPs now have a way of addressing these concerns.

Another big issue is missed appointments. Where patients have a history of this, the Care Navigator can find out why it’s happening. It could be a problem with their memory in which case the Care Navigators can sort out practical solutions like a large print calendar to stick on the fridge. 

I’ve already got GPs saving up lists of patients they want to refer to the Care Navigators. They are really keen to see these new roles up and running.

Care Navigators will also work closely with other health and care professionals, including district nurses, community matrons and social care workers, and can take referrals from them. By getting in early and supporting people to stay well and independent, Care Navigators can help to prevent crisis situations or identify them sooner so there is less need for an urgent or emergency response.


What difference will Care Navigators make to the whole health and care system in Solihull?

Care Navigators are part of a wider system of information, advice and support, which also includes Community Advice Hubs and Local Area Coordination. They are all about getting in early, helping to prevent a crisis happening and supporting people to live independently.

As we do more of this work, we should see a reduced demand for GP services, reduced attendance at A&E and reduced readmissions into hospital. It should also mean that we see an increase in the take-up of preventative services, more people attending their GP appointments and a delay in people’s conditions worsening.

When will we start to see change?

We have already recruited 4 Care Navigators and they are settling into their GP practices in the south of the borough. So far these include: Arden Medical Centre, Coventry Road, Dickens Heath, Dorridge, Grafton Road, Hampton, Haslucks Green and The Jacey Practice. Recruitment is continuing and in total, there will be 12 Care Navigators covering the whole borough.

What are you most proud of so far?

I’m really proud of the way our first group of Care Navigators has approached this new role. It’s still early days because the contract only started on 1st October but Melanie, Eve, Theresa and Alison have got stuck in straightaway. They are learning new ways of working, really getting to know what is going on in their patch and building effective relationships with GPs and practice staff as well as with other health and care professionals supporting the local communities. And it’s great to see the GPs being so positive about Care Navigators.

 

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