Community Health Navigator (CHN) (Community Health Worker) assisted transition of care from hospital to community.

The intervention will be implemented under the SLHD Aged Health, Chronic Care and Rehabilitation (AHCCR) service by Community Health Navigators (CHNs). CHNs are frontline public health workers who are trusted members of and /or have an unusually close understanding of the community served. This trusting relationship enables them to serve as a liaison /link between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. Community Health Navigators (CHN) will follow up patients at risk of readmission on discharge from four Sydney hospitals. The CHNs will provide a minimum of two home visits for each patient (first visit, within the first 72 hours of participant discharge from the hospital and a second visit within two to four weeks from the first visit). The first visit will be of 30 min duration during which the CHNs will : a. build patient understanding of their condition and confidence in self-management. b. identify problems in the living environment that might impact on the patient’s health and wellbeing, including social isolation. c. check medicines with the discharge summary, assessing if they are safely stored and asking about side effects of medicines (to alert GP or other clinical staff). d. monitor self-management. Following the first visit, an action plan will be developed by the CHNs in consultation with the social worker/coordinator attached to the SLHD Aged Health, Chronic Care and service. The action plan will be based on the hospital discharge summary and if relevant, the GPs management plan. Components of the plan will include problems and strategies to address: • Activities of daily living, • Access to food • Housing • Changes to medication, access to medications • Follow visits to GPs, specialist services, allied health services • Language and cultural issues • Social support/isolation At the follow up visit the CHN will be of 30 minutes duration a. review actions and monitor progress from the first visit. b support provided for self- management using translated web- or printed- resource. Translated resource materials appropriate to the individual patients needs will be provided from NSW Health multicultural resource unit, Central and Eastern Primary Health Network, Diabetes Australia, National Heart Foundation, Stroke Foundation, Lung Foundation, Kidney Foundation, Cancer Council. c. communicate by phone or e-mail with the patient’s GP, pharmacist, allied health provider, community health services, aged and/or home care services and other health and/or social care providers. There will be an additional two to four contacts as required up to 60 days in accordance with the action plan to address identified issues at the first home visit. CHNs will record a contact checklist at each visit or contact. This will be reviewed to assess and monitor adherence to the intervention.