Care Navigation steering through stormy seas
I must go down to the seas again, to the lonely sea and the sky
And all I ask is a tall ship and a star to steer her by”
John Masefield from Salt Water Ballads, 1902
Many of us at some point in our lives will need help and direction, especially when life gets complicated and we are faced with uncertainty. The word ‘navigate’ originates from the Latin meaning ‘to drive’ a ship; indeed the seascape of current NHS health and social care is a turbulent one. This is especially true for older people, living with complex mental and physical needs, as a baffling array of services, with different professionals across multiple organisations not communicating with each other. Even those of us working within ‘the system' can be bewildered by it! Sailing a ship through stormy waters therefore needs good navigation with a trusted navigator at the helm.
Quest for integration and co-ordination
The quest for integrated and coordinated systems of care for older adults continues to inspire health and social care policy, more so than ever within the current climate of fragmented services and financial constraint. Whilst there may be no gold standard organisational model for integrated care, what remains a constant and necessary ingredient are people; people skilled and trained to co-ordinate to get the right level of help at the right time.
The concept of 'Care Navigation' though seemingly new, strikes a familiar, timeless chord with most people. It is not the sole fiefdom of NHS organisations and staff - the concerned neighbour or relative who accompanies a patient to memory clinic to help raise important concerns, the volunteer who makes sure someone can get to their doctor appointment, the social worker who helps a patient and carer receive the financial support they need – are all navigators to some degree. ‘Care Navigation’ is a core element therefore of many job roles from those in statutory health and social care, to people working in the voluntary sectors. Some job roles dedicated specifically to care navigation are emerging in different Navigation services throughout the UK, operating within integrated initiatives e.g. the multispecialty community provider care models. Some services provide a one-to-one assessment service for people ‘at risk’, identified by the clinician and care plans (usually older adults with complex multi-morbidity), reviewing people at home or in hospital or over the telephone.
Who are these Navigators? They are usually (not exclusively though) non-clinical staff, who play a vital part in helping to connect people to wider health and well-being and help ‘keep things together’. There are many variations and different job titles, depending on where people operate; such as health and social care navigators, care coordinators and patient liaison officers in primary or secondary sector, non-clinical navigators in A&E and medical assessments units, voluntary sector Age UK locality navigators. In some areas, pre-existing staff such as ward clerks and GP receptionist staff, who have accumulated a wealth of ‘local wisdom’ and already are signposting patients to services, are well positioned to help navigate people to what they need.
Care navigation is thus a key intervention within integrated services where navigators act as a lynch pin to ‘make things happen’ often the very pragmatic, common sense stuff which really matters to people. For example, getting hold of the right person via telephone or understanding a clinic letter, Navigators can help make sure people attend needed appointments, help dispel jargon and communicate next steps with patients and carers. The devastating impact of social isolation in older people on health is recognised, yet the meaningful influence health professionals have can seem limited. Care Navigators help patients and carers interact and connect to different support services based on a person’s needs and aspirations, working at the challenging interface of a whole host of sectors and organisations. This can take imagination, perseverance and ‘thinking outside the box’, for example putting a person in touch with the local choir, a church group or helping to build a person’s confidence and motivation to help themselves, through techniques such as motivational interviewing.
An excellent understanding and local wisdom of services is important. Being an advocate and a friend to people, care navigators are becoming the ‘eyes and ears’ on the ground working closely with their multidisciplinary teams and flagging problems up when others may need to step in, e.g. an acute deterioration in health may need timely clinician input. Age UK Islington locality navigators, for example, work as part of the Islington integrated care team and help link people to voluntary and community services. There is ongoing development for the team of navigators to work also within the local hospitals, seeing people with complex needs before discharge, therefore acting as a key ‘link’ between a potentially vulnerable transition time between hospital and home.
Navigators themselves come from a rich variety of backgrounds including nursing, volunteering, administration and mental health services. Some have experienced illness themselves and are passionate to help others, such as peer navigators for people in hospital who are homeless or have mental health issues.
The emerging evidence base for care navigation services is highly favourable, showing good experiences for supporting patients and carers, some reduction in unnecessary admissions to hospital, preventing falls and easing administrative tasks and time pressures on clinicians. We need to look for ways to support and develop such important work in the future. So be curious; see if there is a Care Navigation service and navigators near you.
Case study: Care Navigator in Harrow, Essex: “An 87 year old gentleman recently came out of hospital. He was thought to be at high risk for unnecessary readmissions to hospital; he lived alone with no next of kin, a host of problems including depression and recent falls – his wife had died a year ago. We discussed him at our multidisciplinary meeting with the district Nurse, Practice Manager, GP and Practice Nurses. We decided that the patient could benefit from a Care Plan. I rang him, explained the benefit of coming in to talk about a Care Plan, and saw him for 30 minutes. The Care plan focused on his wishes and goals, including feeling isolated at home; he was a bit overwhelmed with his tablets and scared of falling over, which made him frightened to leave the house. We talked about some things to work on, including me following up his falls clinic appointment with the hospital. He agreed to look in to a befriending service I found in the area and I booked him in for Medication Review with the GP. He was very happy with this. I find as time goes by I have a good working relationship with the GPs, who are now aware of me, what I can do and how I can help follow up important parts of the care plans, when they are clearly so pushed for time.”
The views of a GP from Newham on care navigators: “The only issue I face with care navigators is not having enough of them! As a GP I see many people whose problems are not medical; the issues are complex, and may be social or housing related. It can feel frustrating knowing the issues but feeling unable to be of practical help, especially with such limited time slots to see patients. I find working with care navigators to be important way to really make a difference to some of my most complex patients. I work closely with our navigator who is brilliant, emotionally intelligent and has time to speak with people who really need some help to get the support from local services. I think excellent communication skills, such as using health coaching, being able to network and build relationships with different professionals are key. It would be great to up skill our receptionist, who is already doing many of these things including signposting people to the appropriate service or help.”
Health Education England North Central East London