Care Navigators work to facilitate integrated working across the Extended Primary Care Teams, GP’s and other stakeholders.
They work closely with GPs, the Extended Primary Care Team and other relevant Health and Social Care Professionals to ensure care delivery is of a high quality and meets required standards and support a defined group of patients that will benefit from a case management approach to empower and promote independence.
They aim to work collaboratively with colleagues in Primary Care to actively seek out patients who will benefit from care navigation and coordination to avoid unplanned hospital admissions, reduce the length of hospital stays and support and promote independence at home.
Being the central point of contact for patients who have been identified as someone that will benefit from the service including moderate to high and very high risk and their relatives/carers and the interface between primary and secondary care providers as well as social care and voluntary organisations.
Identifying and reporting any new problems, changes or concerns in the patient’s or carer’s circumstances to the GP, operational Managers, health care professionals, clinical leads and local authority with a view to facilitating care.
Providing sign posting and link patients, and their carers to other services that would benefit and enhance the patient’s quality of life
Supporting GP’s by being the core member of the wider multi-disciplinary group meetings to establish effective working relationships with patients, their families and carer’s. This will include promoting individual rights and recognising and respecting their contributions to care planning and delivery.
Discussing assessment outcomes with patients, carers and other health and social care professionals and voluntary sector to agree care plans.
Acting on behalf of the patient where appropriate and possible and, by providing information and support, facilitate patients own choices with regard to personal care, promoting independence and self-care as appropriate.
