Frail Elderly 2 - Care Navigation - Sharleen Rudolf

Speaker key

SRSharleen Rudolf

IVInterviewer

SRMy name is Sharleen Rudolf. I am the Care Navigation Manager for Age UK Camden. My talk was about developing a new service, the Care Navigation Service, which will support GPs and the frail elderly and those with long-term conditions within the practices in the MDTs.

IVWhat is the Care Navigation Service?

SRThe Care Navigation Service is a new service delivered by Age UK Camden. It supports the practice to support their pre-frail and frail patients and those 60 years-plus with a long-term or more than one long-term condition. Also for those who have had more than one non-elective admission over the past year, the Care Navigation Service supports these patients within your practice population and it’s a very new service with care navigators based within the practices and it went live on 20th April for referrals.

IVWhere would a care navigator be based?

SRCare navigators are based within the GP practices. They’re situated within a hub practice, which branches out to their outreach practices. These practices are divided into zones across the three localities and there are six zones with six navigators based across the localities.

IVHow do you refer to a care navigator?

SRGPs can refer to a care navigator via their managed referrals on EMIS Web. Referrals come into a centralised inbound referral point. They are then allocated to the named navigators at each GP Practice. Within two days, the navigator will have a face-to-face conversation with the patient and will develop what’s known as a CNAP: a Care Navigation Action Plan. This is a very person-centred approach and they will work with the patient and they will set their own goals. The navigators will act on those goals to produce good outcomes for them.

IVWhat is the aim of the service?

SRThe aim of this service is to improve the quality of life and improve the outcomes for patients within the practice population who are frail and pre-frail, 60-plus, living with one or more long-term conditions. The service develops strong links across health and social care and also into the voluntary sector, to help this practice population to manage themselves better at home, remain independent at home, reduce their sense of isolation, to keep safe at home and also to look at their economical wellbeing.

IVWhere can GPs find out more?

SRGPs can find more on the GP website. They’re also more than welcome to contact me on .

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