Health Navigator Supporting self-management of people living with chronic conditions

Health Navigator is a service that links people living with chronic conditions to the health care they need, when and where they need it. It also supports the development of self management skills. This is a collaboration between WACHS and Silver Chain and is currently a pilot in the Wheatbelt and Central Great Southern regions. Introduction

Silver Chain’s Virtual Health Navigator Service Shared Health Record Standardised Clinical Care pathways and Medical Records Health Care Providers Key elements

Silver Chain’s Health Navigators will act as a system ‘navigator’ for people living with chronic conditions and will provide: a single point of entry for all incoming referrals. holistic assessments to plan interventions support for clients to self manage their conditions and enact management plans. strong partnerships with local GPs. Virtual Health Navigation Service

A shared health record created for Health Care Providers which: enables centralised health care records. allows instant sharing of client information. minimises duplication of assessment and investigation. enables a consistent and coordinated approach. Shared Electronic Health Summary

Review of existing WACHS care pathways and medical records relating to Diabetes, COPD and CCF. Alignment with Best Practice and Clinical Guidelines. WACHS will provide on line training support in best practice internally and links to training for external providers. Clinical Care Pathways and MR

Health Care Providers are our network of health care professionals in the region, who are dedicated to improving the health outcomes of people living with chronic disease. Health Care Providers will be able to: Access the Shared Health Record when appropriate act as Support People for Level 1 clients with chronic conditions Health Care Providers

Improve levels of interagency and multi-disciplinary care. With the clients permission facilitate sharing of health records. Provide easily accessible best practice information. Enhance coordinated care planning. Benefits for Health Care Providers

Support clients to implement the plan you develop with them. Support clients to develop a self -management plan (My plan) with personal goals and actions. Provide information about available services and how to access them. Provide assistance organising referrals and appointments. Benefits for clients

Determine why any appointments have been missed, and try to address issues. Ensure that other health care providers involved in your clients care are aware of the client’s goals and desired outcomes. Benefits for clients

Where TCA are in place a Shared Heath Record will provide evidence of input of other health professionals Health Navigator service will support clients to enact their GPMP and where this is not happening explore barriers with the client and report back to GP via the Shared Health Record The My Plan will sit alongside the GPMP as a complementary tool to assist behaviour change Benefits to General Practice

For more information : Jaclyn Geraghty, Silver Chain, Health Navigator Kiele Robinson, Silver Chain, Health Navigator Karen Beardsmore, SIHI, Primary Care Integration Coordinator Thank you