Connecting Primary Care Providers and Patients to Timely Health and Social Services using Integrated Navigation Models

Core Aim: As the complexity of health care needs of patients with chronic health conditions and multimorbidity increases, care is provided by a wider range of providers and organizations who are often disconnected.  To address this, navigators are being incorporated into various care settings to help connect patients to providers and resources. Many of these navigation models do not involve or connect with primary care providers, the patient’s medical home. This results in confusion, duplication and poor coordination of services with an added layer of complexity for primary care. Building on our previous workshop focused on identifying the key attributes of navigators and efficient methodologies to support integrated primary care, we will expand on this collaborative work towards the development of primary care navigation competencies with a focus on models, skill mix, capacity building, and training.

Background: Our health system has a continued focus on reactive and episodic care for acute illness/injury and exacerbations of chronic disease. Better integration with primary care could allow for improved chronic disease management and health outcomes. Patient and provider co-designed navigation should play a key role in improving this integration.

Aims and Objectives: The aim of this workshop is to broaden our understanding of the requirements of patients and primary care providers in system/resource navigation to meet the health and social care needs of patients.

The objectives for participants - be able to:

1.Identify key components of integrated navigation models to meet patient/provider needs in primary care.

2.Describe the skill mix, training and capacity building for effective primary care provider and patient informed navigation.

3.Apply warm navigation strategies to incorporate the complexity of health needs, health literacy, social determinants of health, language, and culture of patients.

Target Audience: The target audience includes patients, families, primary care providers (including physicians, nurses, interprofessional providers), specialists, home care and community providers, health care administrators, funders, health educators, and acute care providers.

The format of workshop:

1.Introduction: Current state of navigation from a primary care lens. (J Charles 10 minutes)

2.The ideal patient journey: a patient story. (D Wedel 5 minutes)

3.Presentation of skill mix, training and provider/patient communication strategies of current successful models of primary care integrated navigation. (P Pariser 15 minutes)

4.Small group breakout sessions: (F Simone to lead, 30 minutes)

What does it take to navigate and connect with primary care?

How do we implement warm navigation strategies into busy practices?

4. Large group debrief/discussion (D Wedel 25 minutes)

5. Summary (J Charles 5 minutes)

Key Take-Aways:

1.Health and social care system navigation must be integrated with primary care

2.Navigation strategies should be co-designed with patients and primary care providers

3.Methods of connecting and integrating with primary care for efficient navigation

4.The principles of follow-up and follow through are essential.