Developing a System Navigator Role in Primary Care Using a Co-Design Approach

Abstract

Background: Older Canadians with chronic diseases are the biggest users of the health care system. Primary health care services are seen as having a role in coordinating health system access and care for older adults with chronic illness, but at present lacks specific strategies to fulfil this role. The Chronic Care Model (CCM) developed by Wagner and colleagues (1996) provides a framework for developing an effective health care system for chronic disease prevention and management (1). Fundamental to the CCM is the support of productive interactions of patients and families with health care providers, leading to improved outcomes. For older adults with chronic disease and their families, a system navigator role could support productive interactions and effective coordination and navigation through a complex and fragmented health care system. Aims: This project aims to understand how the role of a system navigator can be developed and implemented in primary care. Methods: This study used qualitative methods, within a developmental evaluation approach (2) to develop a system navigator role by working with multiple stakeholders in two communities (one urban, one rural) of Ontario, Canada. Focus group (n=4) and key informant (n=6) interviews with members of primary care teams, representatives of community support services, patients, and their families, were conducted to understand the context within which the primary care teams are operating, available community resources, and opportunities to support system navigation. Data were coded using a line by line, emergent approach (3). These results were reviewed in a workshop which brought primary care and community representatives together to refine the system navigation model and to identify strategies for its implementation. Results: The focus group and key informant interviews identified health care and community needs, resources and opportunities to support system navigation in each primary care centre. For example, community services such as meals on wheels, adult day programs, and exercise programs were identified and charted onto referral maps to be used by the system navigator to link older adults to appropriate resources. Primary care teams and community stakeholders worked in partnership to develop and implement a feasible model of system navigation, in which patients and families are engaged in decision-making around their care. Conclusions: The role of a system navigator was developed in partnerships with older adults, caregivers, and health care providers in order to support older adults with chronic disease(s) as they navigate through the health care system. Limitations: This project was conducted in two Ontario communities. While implementation strategies may need to be tailored to the specific needs and resources of other communities, identified principles for the referral map and system navigator role may be generalizable to other primary care settings. Suggestions for Future Research: The next phases of our work will involve evaluating the implementation and outcomes of the system navigation role, including its impact on patient experiences.