Available programmes: barriers and facilitators

Care navigators were successfully used in the cancer setting (Huber et al., 2014; Natale-Pereira et al., 2011; Willis et al., 2016) and recently within the setting of specific single diseases (e.g. COPD) (Ferrante et al., 2010) or, at particular moments on the care continuum (e.g. the transition between hospital and home) (Jackson et al., 2012). Studies pointed out that widening the use of care navigators in the care system would be beneficial in a society where both specialisation and (lack of) coordination are present (Ferrante et al., 2010; Rein, 2007).

Helping patients navigate the complex and fragmented USA health care system and coordinating their care were central to the ‘patient-centred medical home’. The patient-centred medical home was a new model of care in the USA that ‘aimed to reform the health care system into one that was more patient centred, accessible, effective, safer and efficient’ (Ferrante et al., 2010:736). Similar to the ‘house of care’ in the UK (see section 1.1.3), the ‘medical home’ was introduced in the USA with the aim of providing comprehensive and high quality primary care. It initiated a reorganisation in the way primary care practice was provided in the USA and as such strengthened the overarching health care system (Lipson et al., 2011).

One of the innovations in care navigation was to place care navigators in primary or community care provision. However, integrating this new role in group practices was found to be challenging, with costs and lack of onsite workspace as main barriers (Albert, 2012; Ferrante et al., 2010). Only in solo practices did patient

navigators feel part of the team. In their study looking at patient navigators in primary care, Ferrante et al. (2010:742) stated that ‘although costs of adding staff or IT services are known barriers to achieving a patient-centred medical home, the costs of adding workspace is often underappreciated’. However, their findings suggested that this onsite working space for in-person visits was an important factor in ensuring effective service coordination (Ferrante et al., 2010).

The value of a patient navigator might not have been evidenced at the level of the individual practice, but perhaps more at the wider health care system level (Ferrante et al., 2010). Despite reported benefits, the effort of changing the fundamental care delivery process to support the role of a care navigator was not without obstacles. Providers were often unwilling to fund such a role, despite the evidence of improved outcomes. However, according to Albert (2012), the need for care navigation would become evident in an environment of health care reform. Albert (2012) suggested five steps for the development of care navigation models in health care: determining areas of risk, identifying a target population, finding the right staff to support the model, outlining protocols and best practices, and expanding the scale of the programme. Once developed, these models could tackle some of the health care’s deep-rooted problems such as preventable readmission or redundant and expensive tests (Albert, 2012).

Some studies explored ICT solutions to overcome the challenges to coordinated care or the barriers perceived with ‘a person’ fulfilling the care navigator role (AKTIVE consortium, 2013; Bhandari and Snowdon, 2012; Yao et al., 2012). Issues with communication and information exchange outside the organisation seemed to remain present, often due to technical restrictions on the flow of information (Bhandari and Snowdon, 2012). Personal health records could foster this exchange of information as they allow patients to store, view and share medical histories, medications, etc. (Yao et al., 2012). However, these did not help patients in making

facilitate the process of visiting multiple providers for different purposes (Yao et al., 2012). According to Yao et al. (2012) navigation programmes needed to truly focus on patients in order to help them to manage this task.

In their design of an ICT support tool for navigation, Bhandari and Snowdon (2012) highlighted the difficulty the public found in locating the right services at the right time. Their study looked in particular at LHIN in Canada. These LHIN were expected to plan, identify, integrate and fund health services and priority programmes for their regions. According to Bhandari and Snowdon (2012) system navigation was difficult due to the absence of a system-level navigation tool that gave an overview of the services provided by the LHIN.

Although it could be argued that system navigation is specific to the local health and social care environment (country specific), some problems, difficulties and barriers (e.g. a lack of accessible information on where to go) were considered likely to be seen in other areas (Albert, 2012). In order to help patients in this task of navigation, Bhandari and Snowdon (2012) discussed an on-going system design project of a patient-centred, service-oriented navigation system to be used by the public for accessing regional health care services funded by the LHIN in Canada. Thereby they questioned how the philosophy of service orientation could be applied in this tool and what the role of service design elements was on the user's acceptance and usage of technology (Bhandari and Snowdon, 2012). Bhandari and Snowdon (2012) explored how to close the gap, through technology, between the public and health care services available to the individual. They highlighted that a previous study had explored a system navigation programme, but this was not an automatic computer tool (Bertoni, 2009 in Bhandari and Snowdon, 2012). The ConnexOntario was another attempt in this direction, but was limited because it provided only basic information. For LHIN they wanted to develop service ontology for all the LHIN-funded member agencies. All health services available to the regional population served by the LHIN were reviewed to investigate the

services, the populations served, the access process for each service and the geographic distribution of the available services. Health services were further organised according to the main type of health needs of the population.

All of the provided services were organised into these categories of services and subcategories were identified to provide the necessary level of detail. Underlying service delivery concepts were identified and a prototypical system was developed and successfully validated (Bhandari and Snowdon, 2012).