Evolve


Evolve is a Mental Health Long Term Conditions Navigator Service

Its Aims and Objectives are as follows:
• to support adult service users with a Serious Mental Illness (SMI) in their discharge from secondary to primary care
• to ensure service users attend appointments at their surgery where GPs and Practice Nurses monitor their mental and physical health
• using a person-centred recovery focus, to support clients to reduce any social isolation they may be experiencing by an increased access to a variety of local opportunities/services.

How It Came About — The Mental Health Long Term Conditions Project ‘Evolve’ was originally commissioned in April 2012 as the development upon a preceding primary care community bridge building service which had been in operation since April 2010.

How It Was Developed – Waltham Forest PCT commissioned CREST to develop a Navigators Service to support adult service users with a SMI in their discharge from secondary to primary care. Working closely with a designated Navigator for a period of twelve to 18 months, clients attend between three to four 20-minute appointments at their surgery where GPs and Practice Nurses monitor their mental and physical health. Where any health issues are discovered at these meetings, the Navigator works closely with the client to ensure they attend any out-patient assessments at hospital alongside any pre-requisite health assessments such as blood tests, scans, x-rays. Throughout, Navigators keep regular contact and offer reassurance along with a practical approach. During the twelve-to-18-month period, Navigators use a person-centred recovery focus to support clients to reduce any social isolation they may have been experiencing by an increased access to a variety of local opportunities/services. With the support of the Navigators, GPs and Practice Nurses have successfully managed the discharge of approximately 200 patients across 13 surgeries. Navigators also encourage clients to complete a Wellness Recovery Action Plan (WRAP) as part of their recovery.

Outcomes — The expertise and commitment of the Evolve team has contributed to:
• A reduction in acute hospital admissions
• A reduction by clients at A&E in favour of seeing their GP first
• A reduction by GP’s in re-referring clients back to the Access and Assessment Team
• A reduction in time spent back in secondary care if a client has required input/re-referral
• A reduction in stigma associated with receiving a depot injection at a mental health venue through clients accessing a practice nurse alongside other patients with no mental illness

Contact name and e-mail address — Joss Southcombe, Interim Evolve Team Leader – joss.southcombe@crestwf.org.uk