Service Model

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  • To support and improve GP surgery QOF outcomes for Hypertension, Dementia, Diabetes, Obesity, secondary prevention of fragility fractures (Falls prevention)
  • Reduce GP’s patient workload and time
  • Promote early intervention and prevention through provision of self-management

Health Navigator Role

  • Offer a listening ear, emotional and practical support
  • Identify social needs of patient (Screening)
  • Signpost to appropriate support services
  • Offer patients  self-help strategies, building resilience’s  and self-empowerment 

Service Delivery

  • Service managed and delivered  by Capable Communities
  • Free service, with signposting to wellbeing, advice and info providers
  • Require office space in surgery for 4 hours, 1 day per week within GP practice (flexible arrangements)
  • Set up access to referral forms/directory on Surgery computers.
  • Initial appointment- 30 mins (double session)/ Follow up sessions -15 mins (single session)

Referral Pathway

  • Surgery directs patient to Capable Communities
  • Screening assessment/Allocation from Service Directory
  • Outcomes based provision


For Category 1
Cognition Decreased agitation, better sociability, wellbeing and reminiscence
Falls Prevention Improve self-care, awareness and access, eventually leading to reductions in unintended visits to the A & E and hospitals


Increased knowledge, awareness and understanding on self-care, management, & options on access and referrals to appropriate services
Healthy Eating Adoption of activities and or attitudinal/behaviour changes (Healthy Eating, Exercise, Smoking Cessation, Wellbeing)
Category 2: Advocacy, Advice and Information
Outcomes: Improved knowledge and living situation in relation to Increase in public awareness to appropriate access and management of wellbeing services
Category 3: Wellbeing
Outcomes: Improvement in health and perceived increase in wellbeing (pre & post questionnaire)