Care navigationA new service for Camden’s frail and elderly population

Sharleen Rudolf, Care Navigation Manager

• Trained professionals who work within health and social care to make sure that patients get the care and support they need.

• In Camden, navigators will be focussed on supporting people to access community and voluntary sector services that help them to remain independent and well.

• Care navigators operate across a network of service providers.

Who are care navigators?

• Referral service for patients to non-traditional providers above the level of signposting volunteers.

• Dedicated support for practice and locality level multidisciplinary teams, providing advice, information and coordination across clinicians and voluntary sector / community services.

• Care coordination support for frail elderly and patients with long term conditions who are at risk of ‘did not attend’ (DNA) including escorting and/or use of inappropriate services.

The functions of the service

Bloomsbury

An example of the Hub and Spokes Model: Zone 2 GP practices

St Phillips

Holborn Medical Centre

Museum

Gray’s Inn

Brunswick

Referralsfrom GP

Care navigator

Dedicated support

and access to volunteers

Improving the quality and coordination of care

Referralsfrom GP

Care navigator

Complex case

management

Dedicated support

and access to volunteers

Improving the quality and coordination of care

Referralsfrom GP

Care navigator

Complex case

management

Dedicated support

and access to volunteers

Home visits and follow up

Improving the quality and coordination of care

Provision of a person-centred approach

Identifying problems

Setting individual

goals

Developing a personalised action plan

Working towards the improvement of outcomes

Ability to look after myself

My general confidence

Keeping safe

Managing my money

Meeting people and doing things

Ability to manage my home

Onwards referrals and follow up into voluntary and community services

• Housing and home safety (e.g. cleaning, handyman). • Financial and legal advice. • General advice and advocacy. • Social and wellbeing. • Preventative and health improvement (e.g. falls

prevention classes) .• Mental health support. • Carer support and assessment. • Befriending. • Transport.