Clinical Navigation Hub ( for GPs)

The Clinical Navigation Hub service is available:

8am to 8pm Monday to Friday (excluding Bank Holidays)

The number you need is 0300 2471040

The Hub:
• Point of contact for health and social care professionals
• Comprehensive directory of health and services available across Pennine Lancashire.
• Direct transfer to service or broker referral(s).
• Nurse Advisers support more complex cases.
• Proactively supports your clinical responsibility.
• Work with Integrated Neighbourhood Teams – service options/make referrals
1 call saves you and your team multiple phone calls – gives you more patient contact time.

User feedback to date includes:
“Just to let you know doctor who you spoke to on Friday think’s you’re the best thing since sliced bread and is telling all the other GP’s the same. Keep up the good work!!! Can you send me details of your contact details and I’ll pass them onto the other GPs” Over 75’s Community Sister, Hyndburn

Pennine Lancashire Clinical Navigation Hub Newsletter – July 2015

Recent Hub Examples:
EL GP contacted the Hub to refer 84yr old man; living alone, feels isolated and concerned that nobody will ever know if he dies. Neighbour who checked on him recently died and older siblings are too frail. Patient has poor mobility and had a fall recently so at high risk of falls. Recent significant weight loss and a change in bowel habits; Patient orders food online but GP feels he is not eating a proper meal. Patient consented to all referrals. GP wanted to refer under the 2 week rule but patient declined and refuses to leave the house.
Hub Response including Action Plan: The Hub referred case to social services for commencement of care package and to the integrated therapy teams (Pendle) and Falls Team. The Nurse Adviser contacted Age UK – needs befriending and possible support to empower to ensure patient was fully aware of the GP concerns.
EL GP contacted the Hub regarding a 99yr old lady who lives with her son and is normally quite independent with her ADL’s. Patient has had a recent fall, not sure when or how it was caused; son noticed Mum struggling with ADL’s and would appreciate short term assistance. Patient consented to these referrals. GP undertook to ring the son to reiterate the referrals made on her behalf.
Hub Response including Action Plan: The Hub referred the case to social services for reablement team support; CLO to liaise with patient and her son. Nurse Adviser referred to Integrated therapy service – OT/PT due to recent fall and now reduced mobility. Age UK to provide contacts for befriending service/support for both patient and her son and Carers Link to contact patient.

 

42yr old male patient had a fall at home and called 111. EL GP contacted the Hub after the Paramedics asked GP to visit patient; GP concerned about patient’s poor mental health -history of alcohol abuse and depression. Patient’s mood plummeted since losing his job, was continuing to drink and not eating so becoming malnourished and family struggling with care. Patient consented to all referrals including to alcohol team.

Hub Response including Action Plan: The Hub rang Intensive Home Support who contacted the patient directly. The Nurse Adviser suggested referral to the dietician to counteract any effects malnourishment was having on behaviour. Mental Health accepted referral – patient not known to them – to address long-term history of alcohol abuse (patient had capacity to be assessed). Clinician referrals to Inspire and Specialist Falls Clinic; these were followed up the day after to ensure all referrals had been expedited.

The number you need is 0300 2471040

With effect from Monday 7th September all referrals to the Intensive Home Support Service are to be made directly to ICAT.
Tel number: 01282805989.

This line is available until 10pm evenings and weekends including bank holidays.