health navigator: supporting people living with chronic ... · health navigator: supporting people...
TRANSCRIPT
Health Navigator: Supporting
People Living with Chronic
Conditions
Jaclyn Geraghty, Orla Hill
2 September 2015
• Partnership between WACHS and
Silver Chain
• Assists people to “navigate” the health
system
• Supports the development of self
management skills
• A pilot program in the Wheatbelt and Great
Southern
• Priority conditions of diabetes, COPD and
Heart disease being tackled
Introduction
• It is recognised that country dwelling people
generally suffer more chronic conditions, risk
factors and complications and that this
results in more hospital admissions – than
metropolitan counterparts
• Conversely they have reduced access to GP
and Primary Health Care practitioners
Why do we need Health Navigator?
• Virtual service – all contact via phone or
videoconference
• Clients are triaged at first contact to stream
into care pathways
• Utilise the Flinders Chronic Conditions
Management program to support client care
and foster development of self management
skills
What is Health Navigator
• Encourage the creation of and support
implementation of GPMP
• Provide feedback to health care team from
the clients perspective
• Encourage use of a Client Information
Sharing System
What is Health Navigator
• https://www.youtube.com/watch?v=TzcmhT-
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• https://www.youtube.com/watch?v=CuUgIxrk
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A Client Journey
• Takes place during a project’s implementation
• Aim of improving the project’s design and
performance.
• Compliments summative (outcomes)
evaluation
Formative (Process) Evaluation
• Conduct holistic risk assessment/triage
• Act as a ‘system navigator’
• Support clients to better self-manage their
condition and/or implement their GPMP
• Deliver consults via videoconference or
telephone
• Facilitate multidisciplinary, interagency care
• Develop a client database for health
professionals
Health Navigator Service Objectives
• Client feedback surveys
• Client data analysis
• Survey of external health
service professionals/providers
• Feedback interviews with Health Navigator
project staff
Methods
Strongly
Disagree
(%)
Disagree
(%)
Neither
(%)
Agree
(%)
Strongly
Agree
(%)
Total
Agree
(%)
The Health Navigator staff are friendly
and approachable0.00 0.00 2.33 46.51 51.16 97.67
The Health Navigator staff know what
they are doing2.38 2.38 4.76 47.62 42.86 90.48
The service gives me enough
information on the things I need to
know about
2.33 2.33 4.65 53.49 37.21 90.70
The service helps me to better
manage my health2.38 0.00 16.67 45.24 35.71 80.95
I am satisfied with the service as a
whole4.55 0.00 9.09 45.45 40.91 86.36
• 259 surveys mailed, 50 returned 19%
Client Feedback Results
11
Client Feedback Results
12
How helpful has the
Health Navigator been to:Not helpful
at all (%)
Not so
helpful (%)Neither (%)
Somewhat
helpful (%)
Very
helpful (%)
Total
helpful (%)
Teach you how to stay as
healthy as possible?4.88 0.00 2.44 39.02 53.66 92.68
Help you to see other
health care people and
services?
7.89 2.63 15.79 18.42 55.26 73.68
Improve your overall
quality of life?5.26 2.63 13.16 34.21 44.74 78.95
Reduce the number of
times you visit your
doctor?
5.56 5.56 22.22 27.78 38.89 66.67
Help you work out your
goals and how to get
there?
4.88 4.88 12.20 26.83 51.22 78.05
• In the first 18 months, 360 clients
• Half were Level 2, 38% were Level 3 and
14% were Level 1 at baseline
• At follow up the majority of clients were the
same risk level, however 28% improved
Client Data Analysis
Client Data Analysis – Flinders Partners
in Health Scores at Follow Up (Example)
Worse
(% of
clients)
No Change
(% of
clients)
Better
(% of
clients)
1Overall, what I know about my health condition(s) is:
(Very little – A lot)6 67 27
2Overall, what I know about the treatment of my health
condition(s) is: 7 68 25
3I take medications or carry out the treatments asked by
my doctor or health worker: (Never – Always)4 80 16
4I share in decisions made about my health condition(s)
with my doctor or health worker: 9 77 15
5
I am able to deal with health professionals to get the
services I need that fit with my culture, values and
beliefs: 7 75 18
6I attend appointments as asked by my doctor or health
worker:7 79 14
It was envisaged that videoconferencing
would be the main mode of service
delivery, but … clients prefer not to travel
Client Data Analysis –
Telehealth/Videoconferencing
• Two thirds thought theHN service facilitates
multidisciplinary, interdisciplinary care
• While the majority see the value of the CISS,
few currently use it
• Majority neither agreed nor
disagreed that they were
satisfied with the service
• Users of the service
were generally positive
External Health Provider’s Feedback
• Difficulties using some of the Flinders
tools over the phone
• Caseload needs to be determined
• Timeframes need review
• Plan needed for involving GPs
• Emphasis placed on GPMP needs
review
Health Navigator Staff Interviews
• Conduct holistic risk assessment/triage
• Act as a ‘system navigator’
• Support clients’ to better self-manage their
condition and/or implement their GPMP
• Deliver consults via videoconference or
telephone
• Facilitate multidisciplinary, interagency care
• Develop a client database for health
professionals
Discussion – Does the Service Meet
Objectives?
• The service has been successful in meeting many
objectives
• Clients are generally satisfied
• Preliminary analysis shows improvements in ‘risk
level’ and Flinders PIH scores for small numbers
• Still too early to review health professionals
satisfaction
• Suggestions for improvement being operationalised
• Qualitative interviews with clients and health providers
and costing study to follow
Conclusions
This project has been funded through the Royalties for Regions,
Southern Inland Health Initiative
Thank you