We are a non-clinical, non-patient facing role who work collaboratively with Health & Social Care services. We are based within Primary Care Networks (PCNs) across the City. This means we have a geographical focus that enables us to respond and adapt to local Health & Social Care needs.

As Care Navigators we are responsible for coordinating information to support the assessment of a patient. GPs and members of the PCN neighbourhood team such as Community Nursing, Cardiac Rehab, and Community Rehab and Falls. 

We are an integral part of the delivery of Multi-Disciplinary Team (MDT) meetings. We use risk stratification software to identify gaps in Health & Social Care for our patients to support & reduce hospital admissions. Any complex cases identified a complex MDT will be arranged, this often includes Community Nurses, Specialist teams, Police, GP & Social Care. We are responsible for coordinating the meetings, from invites to setting the agenda & writing minutes.

Other responsibilities include:

  • Tracking Community patients in and out of the hospital to support a safe discharge & to inform our Community teams of admission into the hospital
  • Daily checks of patient records identified by risk stratification software to identify possible Health & Social Care gaps 
  • We have access to patient records across the health system, including GP practices, community services, social care and hospital. This supports better health & social decisions for our patients across Nottingham City.
  • Contact hospital wards for updates on a patient’s condition to inform community teams 

We also process referrals from our Primary Care Network team into the following services to free up clinical time: 

  • Community Nursing Team (District Nurses, Matrons & Rehab & Falls)
  • Social Care (excluding safeguarding referrals)
  • Medicines Management
  • Social Prescribing 
  • Assistive Technology 

Referrals come directly to us from health professionals. Patients cannot refer directly into this service.