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Nurse Navigator Service

Nurse NavigatorsIn 2016 the Nurse Navigator program was introduced in Queensland. Led by the Office of the Chief Nursing and Midwifery Officer, Clinical Excellence Division, the Nurse Navigator Service provides dedicated roles to facilitate the journey of patients with complex healthcare needs through an increasingly complex health-care system.

With the GP as the primary care provider and case manager, the nurse-led model of care provided by Nurse Navigator Service assists patients to navigate the complex healthcare system, from the community or primary health care setting, through hospital, and back home again. By working across multiple specialties, the Nurse Navigator Service aims to reduce service fragmentation and improve access for patients through care coordination, advocacy and education.

As highly experienced clinicians with an in-depth knowledge of the health system, Nurse Navigators support patients to improve their health literacy and capacity to self-manage their conditions. Nurse Navigators assist patients to access services in the right place, at the right time and by the right health-care professional or care provider.

Reference

Nurse Navigator positions in Queensland’s public health system have provided dedicated roles to facilitate the journey of patients with complex healthcare needs through an increasingly complex health system. Nurse Navigators work to reduce fragmentation, mitigate barriers, educate and empower patients and assist in the coordination of care. The Nurse Navigator model of care has the General Practitioner as the primary care provider and case manager of their referred patients.

Nurse Navigators link with General Practitioners who identify and refer their most complex patients (adult or children), who require a coordinated approach to improve their health outcomes. Based upon similar criteria, other referrals to the service will come from specialists, hospitals and hospital data bases.

Referral Criteria

Patients of all ages are eligible.

Clarification of eligibility is undertaken by the Nurse Navigator focusing on those patients with the most complex needs, and working towards closing the gap for Aboriginal and Torres Strait Islander patients. Suitability of admission to the Nurse Navigator Service is based upon the areas of chronicity, complexity, fragility and intensity of care.

Referral eligibility criteria diagram (PDF, 2244 kB)

Reason for referral may include:

  • Supporting general practitioner care plans and referrals made
  • Complex medical concerns
  • Multiple co-morbidities and health care providers
  • Difficulty self-managing
  • Frequent hospital presentations / at high risk of representing
  • Complex biopsychosocial or environment challenges
  • Assistance with multiple SCHHS outpatients and specialist appointment navigation
  • Increased vulnerability that impacts on healthcare
  • Holistic assessment
  • Supporting G.P. care plans and referrals made
  • Coordination of appointments
  • Supporting health literacy
  • Linkage to appropriate options / services
  • Health coaching and goal setting
  • Care coordination and advocacy role
  • Advance Care Planning
  • Provide in-reach to the acute sector upon patient admission.

How to submit referrals

ServicePhoneFax
Accepts referrals via eReferral to SCUH Central Referrals ADD (preferred method) or fax to Community Intake.0438 839 791 or 0429 678 948 (07) 5479 9673
Last updated: 29 November 2018