Personalised care programmes
Care navigation programme
Our Care Navigation Programme provides tailored training for your staff to signpost people to local community resources, empowering them to manage their personal needs and reducing their reliance on GPs. The three main aims of the programme are to:
- Reduce unnecessary GP appointments
- Increase patient wellbeing
- Maximise resources already in the system
Our experienced team at the National Association of Primary Care (NAPC) trains a range of frontline staff – including receptionists, admin staff and pharmacy assistants – to actively listen and signpost people to sources of help, advocacy and support. Patients may be signposted to local charities, social services, their local pharmacist or community services. Primary Care Navigators are also trained to help people play an active role in managing their own health.
Care navigation development
Care Navigation Training is suitable for a wide range of primary care staff working in non- clinical roles including GP receptionist and administrative staff. Team members involved in providing clinical services such as phlebotomy or HCA roles can also benefit from this training.
There are a wide range of models in use for delivering care navigation and this is continuing to change as roles such a health coaching and social prescribing link workers become more routinely part of primary care teams. Care navigation may include:
- Providing sign posting to organisations and services as part of ad hoc conversations with patients during appointment making or
- Providing dedicated care navigation appointments to discuss signposting or referral to other services following a clinical appointment e.g., diabetic patients having a follow up conversation with a care navigator to access exercise, smoking cessation or weight management support following a GP appointment. The aim is to put the patients in touch with specialised (and often non-clinical) services as part of their ongoing and holistic
- Compiling resources e.g., notice boards and leaflets for helpful partner organisations or a local directory of services (although these re increasingly produced by local councils and wellbeing services).
- Targeting population health management interventions from risk stratification data especially regarding social needs. For example, supporting patients with diabetes to access exercise, smoking cessation, or weight management
- Holding events to connect groups of patients to support services and groups e.g., coffee mornings for carers with local organisations that may provide carer support, patient support groups or the Citizen’s Advice
- Providing a listening ear and empathy to patients who know seeing the GP is not what they need but not knowing who else to talk
In this model, care navigation is not clinical triage or advice giving “What you should do is…” It forms a useful part of the integrated primary care team and supports both meeting the wider and non-clinical needs of patients and can release clinical time.
This role dovetails with the Social Prescribing Link Worker role but is practice based and deals with patients with less complex needs than those typically seen by SPLWs. Care navigation may often include signposting a patient to the SPLW for further support following a GP or Practice Nurse consult.
Care Navigation training
Our current on-site training package involves a Foundation Day, suitable for all non-clinical staff and a further day focused on communication and health coaching skills. All training is highly interactive and experiential and is geared to maximise participation and impact for non-clinical staff. Where we differ from other trainings is that we connect your practice staff directly to partner organisations, giving them the confidence to signpost appropriately.
NAPC has translated its care navigation training to a virtual modular package. Modules are likely to be two hours in length, it is likely that there will be two modules for the Foundation training and two further modules for the Communication skills development. Plus, a learning transfer session.
Foundation Day – 2 modules – up to 25 delegates per cohort
Defines the boundaries and function of care navigation
- Builds confidence in signposting patients
- Connects participants directly to useful local partner organisations – partner organisations come along to the training to talk about what they can
- Builds a community of Practice across Practices or PCNs
Communication Skills Course
Communication and Coaching Skills – 2 modules – up to 25 delegates per cohort
This is a more in depth and skills-based training, providing participants with both theory and practice on holding more effective conversations with patients. It is based in coaching and Motivational Interviewing theory and is suitable for those with a stronger interest in developing their care navigation skills and for those who are taking on dedicated roles in care navigation and health coaching. It includes:
- Understanding why advice rarely works – Human behaviour change and habit formation
- Emotional intelligence and recognising our role in the conversation
- An introduction to Every Contact Counts and healthy lifestyle information
- Skills in building rapport, listening and asking open discovery questions
- Professionalism including confidentiality, note keeping and being part of the integrated team.
Learning Transfer Session
At NAPC we recognise the need to put learning into action. Training and development are expensive and we want your investment to translate to improvements in patient care. 4-6 weeks post training, a short further session is provided to ensure delegates are putting what they have learnt into practice, to troubleshoot difficulties and action plan for further implementation and sustained change.
This has been offered via a further an on-site short meet up (2 hours) or individual or practice based coaching calls.
We may also be able offer more bespoke training offers for example in having difficult conversations. These would involve additional cost to cover development of the training.
Please contact Sally Kitt if you have any queries or training requirements: firstname.lastname@example.org.
The growth of the programme
The NAPC has trained nearly 300 care navigators with different programmes tailored to meeting the specific needs of patients with dementia, diabetes and long term conditions. Other programmes have focused on the frail and elderly and patient wellbeing. Interest in Care Navigation training is growing as word spreads about the success of the programme and many primary care home (PCH) sites are planning to invest in developing their staff to become navigators – a recommended element of the PCH model.
About the programme
This is a bespoke programme tailored for your needs and co-designed with your team. It is often delivered over 12 months but can be shorter or longer. It usually involves four phases:
- working with you to understand the local health and care landscape
- facilitating sessions between health, social care and the third sector to galvanize everyone to work together in the best interest of people in the local area
- leading and delivering the programme
- initiating learning transfer sessions.
Delivering a range of benefits
The programme delivers benefits for patients and staff and maximises resources by:
- Reducing unnecessary GP appointments, so allowing more time for patients who need diagnostic and complex medical care
- Supporting and empowering patients to manage their own health and wellbeing
- Improving staff morale and retention
- Connecting you with other organisations and improving signposting across the whole of your local community
Here’s what some of those who’ve been through the training say about the difference it’s made:
“As primary care navigators we have been able to identify and tap into available money and resources to support people – demonstrating that despite it being a time of austerity, with a reduction in services and resources, there are resources in abundance once you start to look…and there’s also a lot of duplication.”
Who should receive the training?
We typically work with receptionists, health care assistants and pharmacy dispensers but all frontline staff can benefit from the training. You don’t need to be part of the PCH programme to benefit from the training. But what you do need, for the training to be successful, is a strong commitment to collaboration and staff development and an appetite to work and share learning with health, social care and the voluntary sector.
Why choose us?
The NAPC has delivered training programmes for GP federations, clinical commissioning groups (CCGs) and Health Education England, so we bring a wealth of experience and learning from across the country.
We are delivering the primary care home programme – which is at the centre of redesigning integrated care with more than 180 sites across England. The model brings together a range of health and social care professionals as a complete care community to focus on local population needs and provide care closer to patients’ homes. Our primary care navigation training is a key element of the PCH programme.
A case study – how primary care navigation helped hospital admissions fall by 80%
At the Oxford Terrace and Rawling Road Medical Group in Gateshead, two of the practice’s healthcare assistants received online training and peer support to help understand dementia and ways of providing non-medical support to patients and their carers. After undergoing the training, each healthcare assistant spent half their time acting as a navigator, helping to connect vulnerable patients with care and support in the community and providing direct, non-medical support.
They received referrals from other members of the practice and in their other role, as healthcare assistant, they identified patients who would benefit from extra help and support.
They spent time getting to know each new patient and their carers, identifying unmet needs and connecting them with sources of support. They found common issues included social isolation and inactivity and they built up an extensive knowledge of the local voluntary and community groups that could help. The navigators also acted as a first port of call for nursing homes, handling issues such as prescription and visit requests and coordination of services on discharge from hospital.
The navigators provided some direct support to patients and carers themselves through regular fortnightly phone contact or a home visit, open invitations to the surgery for a “catch up and cuppa” and regular social events bringing together people in similar circumstances.
An evaluation by Deloitte reported that in the first three months the navigators supported the GPs at the practice with screening 117 patients for dementia, agreeing 396 care plans with patients and connecting 43 carers and 20 veterans with local services. They undertook post-discharge support, coordination of services and medication for 86 patients, removing the need for a GP appointment. Hospital admissions fell by as much as 80% for patients in contact with the navigators.
Community engagement and social prescribing support
NAPC has partnered with the National Association of Link Workers to offer health systems expert support on developing innovative community engagement and social prescribing.
Working with you, our team can design a bespoke package tailored to the needs of your health system. Here are some examples of how we can work with you:
- Advise on how to embed person-centred and community-centred approaches
- Support your health system to take a community engagement approach to get to know your population and their health needs
- Guide you on social prescribing from mapping community assets, recruiting link workers, providing link worker development and building their resilience and developing a full social prescribing programme
- Support with developing an integrated personalised care offer and a local community of practice for personalised care roles
- Support you to develop your receptionists, practice managers, nurses and pharmacists in active signposting through our well-established and enhanced care navigation programme
- Assess your community engagement approaches and develop an action plan with a focus on population health.
More details about this joint support offer can be found here.