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 Plugs in Here!

Non Traditional Providers? Neighbourhood Resources Library Fire Service Parks Faith Groups Organisation Groups Circles Rotary/WI Support Group Cancer Dementia MS Leisure Facilities Sports & Fitness Arts Clubs/Activity Centres Day Centres Community Activities Self run Interest groups Organised Volunteering Circles Groups 50+ membership groups Navigators Onward referrals Local Businesses Cafes for socialising Local Shop Access Points Third Sector Providers Befriending Specialist advice

Practicalities 2 full time posts 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 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. 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 Current Outcomes framework and monitoring

Enabling/Self Management Approach Mrs A 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 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 Mrs B 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 Case Examples of experience with complex cases, involving high levels of liaison

Questions What navigation roles do you currently have? How would you like the navigation system to work to support your organisations? How can you help us further support and develop the navigator role?