Care Navigators – Link me plus

Link-me+ for Care Navigators

What is Link-me+ ?

Link-me+ is an evidence-based, patient-centred, stepped care approach to support patients’ mental health and wellbeing in primary care settings. After completing the Link-me+ questionnaire, patients who are identified as having higher intensity care needs can be referred to a Care Navigator. Care Navigators are nurses, allied health or community mental health professionals trained in the Link-me+ model to provide tailored support to patients to improve their mental health and wellbeing.

What is the Link-me+ approach to Care Navigation?

The Link-me+ approach to Care Navigation is informed by the principles of collaborative care, including the following key characteristics:

Reference: https://link.springer.com/article/10.1186/s12913-021-06307-5
Or
See: McKenzie, K. J., Fletcher, S. L., Pierce, D., & Gunn, J. M. (2021). Moving from “let’s fix them” to “actually listen”: the development of a primary care intervention for mental-physical multimorbidity. BMC health services research, 21, 1-13.

The model of Care Navigation in Link-me+ is informed by behaviour change theory, expert consensus guidelines and clinician perspectives. Click here to read more about Care Navigation research

What happens in the first Care Navigation session?

Informed by the patient’s responses to the Link-me+ questionnaire, the goals of the first Care Navigation appointment are to:

Engage the patient in the Link-me+ Care Navigation program

Build a comprehensive understanding of the patient’s situation

Identify the patient’s priorities and goals

Elicit and reinforce the patient’s own reasons for making changes

Start to develop a plan for actions that can lead to better mental health and well-being.

“She likes the … approach, as during the last two years that she has been receiving psychological support no one has ever asked her ‘what is important to you?”

Care Navigation Nurse, Target-D Written Session Log

What happens in the follow up Care Navigation sessions?

Check in with the patient about how they are feeling, and monitor symptoms

01 Review the progress of the action plan, emphasising steps taken, and problem-solving together if additional support is needed

02 Keep the GP in touch with the patient’s progress and seek their input if needed

03 What is motivational interviewing?

Motivational interviewing (MI) is a collaborative and person-centred approach to communication that is particularly helpful for conversations about change.
The Link-me+ approach to Care Navigation draws on motivational interviewing, using strategies like directional open questions, reflections, importance and confidence scaling and collaborative information sharing.

Partnership

Working together with patients to better understand what is happening for them and what changes might be possible

Acceptance

Respecting the patient’s worth and autonomy and responding with accurate empathy and affirmation

Compassion

Promoting the wellbeing of the patient and prioritising the patient’s needs

Empowerment

Helping the patient realise and use their own strengths and abilities

The Building Blocks of Care Navigation

Care Navigation includes the mechanisms of engagement, finding a focus and empowering patients to make changes. These mechanisms are shown in the figure below, highlighting the MI skills that align with a care navigation approach

Link-me+ Care Navigation