Community health navigators in Australian general practice: an implementation study
Cathy O’Callaghan A * , Elizabeth Harris A , Sabuj Kanti Mistry B Mark F. Harris
A
A
B
Abstract
Patient health navigators have an emerging role in assisting people to connect with health and social care services especially those experiencing language and communication barriers. A challenge with navigator programs is sustaining their implementation. This study evaluated the implementation and sustainability of bilingual community navigators (BCNs) in multilingual general practices in Sydney and their impact on patient access. The hypothesis was that the use of bilingual navigators within multilingual practices would be acceptable and feasible, improve patient access to appropriate care and staff workload, and reduce health inequities.
Patient referral information was collected and analysed descriptively. Interviews were conducted with practice staff, patients, and navigators after 10-week placements and analysed thematically using Normalisation Process Theory.
A total of 110 patients were referred to navigators who assisted with booking appointments, accessing community resources, and translating and explaining information. Interviews were undertaken with four navigators, three patients, three carers, and four GPs. Practice participants could see the benefits of the BCNs and were motivated to engage with them, especially with GP endorsement. However, not all understood the navigator competencies and roles. In some practices, the population needs and the scheduling of appointments and staff routines could have aligned better, which constrained referrals and continued navigator involvement.
This study demonstrates the potential role of navigators in addressing navigation challenges experienced by culturally and linguistically diverse patients in general practice. More effort is needed to tailor attachments to the unique needs of the patient population and practice schedule. Sustainability requires ongoing funding and broad institutional support.
Keywords: Australia, community health workers, culturally and linguistically diverse, healthcare navigation, health and social care, health equity, implementation, primary care.
Introduction
Patient health navigators have an emerging role in assisting people to connect with appropriate care in the increasingly complex Australian healthcare system (Peart et al. 2018; Harris et al. 2024; Neadley et al. 2024). These specifically address the needs of patients who are aged, have multimorbidity, and who experience barriers to accessing care especially due to stigma and social and economic disadvantage (Calder et al. 2019). They often have a specific focus on culturally and linguistically diverse (CALD) people who often experience language and communication barriers to access health and social care services (Khatri and Assefa 2022).
Internationally and locally, there is evidence that community health workers (CHWs) are effective as patient navigators in helping patients navigate health services and thereby can help prevent hospital admission and readmission, promote self-management, and reduce demands on local health services (Kangovi et al. 2017; Egbujie et al. 2018; Javanparast et al. 2018; Mistry et al. 2021). They can achieve this by facilitating better access to a range of health and social care services, improving health literacy, and addressing health inequity (Knowles et al. 2023).
One of the challenges with these navigator programs is in sustaining their implementation, especially at scale (Valaitis et al. 2017). Factors identified in implementation research as influencing their success include: the provision of long-term funding; clarity about their roles and ongoing training; supervision and accountability within the health and social care systems; the culture and attitudes of other members of healthcare teams; and the relationships and partnerships with other services and community organisations (Valaitis et al. 2017).
This paper describes the second of two research studies focused on exploring the introduction of bilingual community navigators (BCNs) into Australian general practice. The first study confirmed the feasibility and acceptability of placing BCNs in bilingual general practices (Mistry et al. 2023). The current study aimed to evaluate the implementation and sustainability of the BCNs in general practice and their impact on access to services and on the practice staff and their workloads.
Methods
This study followed a cross-sectional post intervention qualitative research design. In the previous study, following extensive interviews and a codesign process, the role of the community health navigators and training program was developed (Mistry et al. 2022a, 2022b). This was then qualitatively evaluated in the feasibility and acceptability study (Mistry et al. 2023). In the present study, after further refining the training, we sought to extend the study to other practices and cultural groups and specifically focus on implementation using Normalisation Process Theory (NPT) (May et al. 2018).
Practice selection
The study was carried out in five bilingual general practices that expressed interest in participating. The included practices (and the respective priority language groups) for this research were:
Lakemba Family Health Care, Lakemba. (Arabic)
Quality Medical Care, Merrylands. (Arabic)
Wolli Creek Medical Centre, Hurstville. (Chinese)
Powell Street Medical Centre, Yagoona. (Samoan)
HealthPac Medical Centre, Hurstville. (Chinese)
There was no financial incentive to GPs (other than not having to pay the BCNs). The GPs committed to having a BCN placed in their practice for 4 hours per week over 10 weeks and offering patients the option to receive navigation support from the BCN to assist them in accessing health services.
Selection and training of BCNs
Lay people were recruited from the community with cultural and language backgrounds matching the needs of the practices. They expressed interest following information circulated by the practices, local health districts, and local multicultural community organisations. Those who expressed interest were interviewed and selected based on merit. Priority was given to recruiting people with local knowledge and connections. They did not necessarily require a specific health qualification. The training was based on the previous codesigned training program (Mistry et al. 2022b; Harris et al. 2024). This was a structured online self-paced program (24 hours), comprising 12 modules including notes, presentation slides, suggested reading, supporting videos, and a quiz to assess the level of knowledge and skills the BCNs acquired from each module (Table 1). It also included a 4-hour face-to-face meeting with the BCNs to discuss issues related to the implementation in practice. A training log recorded each BCN’s completion of the training modules, attendance at the face-to-face workshop, and performance in the assessment following each module (having to achieve at least 80% success in the assessment).
| Module | Topic | |
|---|---|---|
| 1 | Understanding the Australian healthcare system | |
| 2 | Introduction to chronic disease | |
| 3 | Preventive health care – risk and protective factors | |
| 4 | Social determinants of health | |
| 5 | Community health navigators: roles and responsibilities | |
| 6 | Cultural mediation and language | |
| 7. | Communication and self management | |
| 8 | Community resources | |
| 9 | Client needs assessment and problem identification | |
| 10 | Professional responsibilities and boundaries | |
| 11 | Medicines and medication adherence | |
| 12 | Access to health care |
Placement in general practice
Each BCN was placed in a general practice for 10 weeks. In each practice, the GP or other clinical staff referred the patients requiring navigation assistance to contact the BCNs. The eligibility criteria for the patients included adults receiving care from the practices and who required navigation assistance to access health and social care. These patients were offered navigation support if they consented to participate. The patient was able to contact the navigator face-to-face in the practice or over the phone. If the patient did not contact the navigator, the GP may ask the BCN to contact the patient (having received patient consent for this to occur). The BCN met the patient on one or two occasions lasting for 30–60 min.
The role of BCNs was to provide:
−Navigation assistance before and after patient appointments, including navigation to referral services and providing information about the service and cost, overcoming barriers to patients attending, and facilitating transport.
−Communication assistance during an appointment to overcome patients’ language barriers but not act as a medical interpreter. This may include providing patient support at appointments.
−Health literacy support through the provision of in-language community education by the BCN on health topics identified by GPs.
The BCNs had regular contact with the Project Coordinator who provided mentoring support with problems identified and any issues raised. Two catch ups were also held with the research team during the placement to discuss progress. The research team also maintained regular contact with the practice staff during the intervention to help gain insight into the progress of the intervention and resolve any issues that may have arisen.
Data collection
During the intervention, there was ongoing monitoring of the activities of the BCNs through completion of an activity logbook containing information on the tasks undertaken and times taken during the intervention. These were used to identify the workload and scope of the BCN’s work. The logbook contained non-identified information on the date of patient visits, age-group of each patient, country of birth, main health problems, reason for referral to BCN, service(s) that each patient was referred to, key issues or problems identified, what navigation help was offered, how long the BCN spent with each patient, and if the patients subsequently attended the referral service (if known). This information was regularly shared with the research team and the GP where the BCN was based.
Qualitative interviews were conducted with practice staff, patients, and BCNs at the end of the 10-week placement from the participating practices. These were conducted using interview guides for BCNs, patients, and practice staff and audio recorded. The interview questions were based on previous research and consultations (Mistry et al. 2022a, 2022b, 2023). Patients were purposely selected from the practices to ensure representation of different practice populations (age, ethnicity). The interviews were conducted by a research team member (CO). Two interviews with patients were conducted in Mandarin by a previous BCN from the first study and then translated into English by an interpreter and then transcribed. One interview with a patient was conducted in Arabic by the alternate Arabic speaking BCN, then detailed notes provided in English.
Analysis
Interview transcripts were reviewed and coded according to patterns and themes that emerged from the data (Green and Thorogood 2018). The sample size estimate was based on the number required for similar qualitative case study research (Schütze et al. 2018; Mistry et al. 2023). Data collection ceased once the analysis was theoretically sufficient to meet the research aims (Braun and Clarke 2021). The evaluation assessed the acceptance of the BCN role, its perceived fit with the practice and factors influencing this, and its perceived benefit to patients and practice staff.
NPT guided the analysis (May et al. 2018). Four constructs representing the factors influencing how the intervention was implemented included coherence, cognitive participation, collective action, and reflexive monitoring (May et al. 2018). These components (Table 2) were used to interpret the factors that participants identified as inhibiting or promoting incorporation of the intervention into usual practice (Alharbi et al. 2014). To ensure reliability and validity of the qualitative data, the completed coding framework was reviewed by project members so that variations in understandings could be refined and validity increased (Green and Thorogood 2018).
| Concept | Definition | |
|---|---|---|
| Coherence/sense making | This is the sense that people make of an intervention, their shared understanding of program objectives and benefits, individual roles and tasks, and the inherent value of the project | |
| Cognitive participation | This is the commitment and engagement of participants including their motivation to ‘build and sustain’ practices; engage others; and ensure sustainability | |
| Collective action | This is the work done to enable interventions to happen. This depends on the workforce having the right skills and enough time and resources | |
| Reflexive monitoring | Reflexive monitoring is the appraisal done by people to assess the intervention impact on themselves and others including its effectiveness; and how its procedures can be refined based on feedback |
Consent to participate
All participants gave full informed consent to participate in the research. Full written informed consent was given by the health professionals to the researcher CO to participate and be interviewed. Patients and carers provided BCNs with written or verbal consent to participate, and full written consent was provided if they agreed to be interviewed.
Results
BCN placements
BCNs were placed in five practices with a predominant language group other than English – one Samoan, two Arabic, and two Chinese. One Chinese practice and its BCN withdrew because the GP could not identify patients for referral who could attend the practice during the times that the BCN was in the practice. Chinese speaking patients attending the practice tended to be younger and less frequently requiring navigation support. Similarly, there were too few patients in one of the Arabic practices requiring assistance so that the two BCNs were relocated to another Arabic practice.
BCN referrals and actions
A total of 110 patients were assisted by the BCNs; 99 having one visit and 11 having two or more visits. Fourteen percent were aged under 45 years, 41% aged 45–64, and 45% aged 65+ years. Thirteen percent were born in Arabic speaking countries, 41% from China, 40% from Samoa, and 6% from other countries. Patients who accepted the offer to have a BCN had a wide range of predominant medical conditions, most frequently diabetes and cardiovascular conditions. Patients were referred for appointments with hospital outpatients, medical specialists, and allied health professionals.
The barriers identified by BCNs were language, access to services, cost, transport, legal, work, disability, social care, health literacy, financial support, mental illness, medication adherence, and immigration. BCNs responded with a wide range of activities to assist patients; most frequently helping them to book appointments, arrange access to community resources, contact the service on behalf of the patient and GP, translating and explaining information, and providing help with paperwork or information about their appointments (Table 3).
| Action | 1st study (Mistry et al. 2023) (n = 95) (more than one option) | 2nd study (present study) (n = 110) | |
|---|---|---|---|
| Booking appointment | 52.6 | 45.4 | |
| Arranging access to community resources | 12.6 | 9.3 | |
| Contacting service on patient’s behalf | 34.7 | 8.3 | |
| Arranging a blood test | 7.4 | – | |
| Translating and explaining referral | – | 6.5 | |
| Help with paperwork | 5.3 | 6.5 | |
| Providing information about appointment | 46.3 | 5.6 | |
| Seeking information from others | – | 4.6 | |
| Providing help with transport | 8.4 | 3.7 | |
| Supporting family or carers | – | 2.8 | |
| Assisting with cost/finance/benefit | 23.2 | 2.8 | |
| Providing information about condition | – | 1.9 | |
| Arranging follow up appointment with GP | – | 1.9 | |
| Emotional support | 15.8 | 0.9 |
Qualitative interviews
Fourteen interviews were undertaken with four BCNs, three patients, three carers, and three GPs (Table 4). These were analysed using the four elements of NPT.
| Category of participants | Age | Gender | Language | ||||
|---|---|---|---|---|---|---|---|
| BCNs | 19–44 | 1 | Male | 0 | Arabic | 2 | |
| 45–64 | 2 | Female | 4 | Chinese | 1 | ||
| 65+ | 1 | Samoan | 1 | ||||
| Drs | 19–44 | 1 | Male | 2 | Arabic | 1 | |
| 45–64 | 3 | Female | 2 | Chinese | 2 | ||
| Samoan | 1 | ||||||
| Patients | 19–44 | 2 | Male | 1 | English | 1 | |
| 45–64 | 1 | Female | 2 | Chinese | 1 | ||
| Samoan | 1 | ||||||
| Carers | 19–44 | 2 | Male | 1 | Arabic | 1 | |
| 45–64 | 1 | Female | 2 | Chinese | 1 | ||
| Samoan | 1 | ||||||
The staff and patients reported that the BCN program greatly assisted all the patients that were referred to it in general practice. It made sense to provide it, and it brought perceived benefits to GPs, BCNs, patients, and their families. It reduced the workload of the practice staff in assisting patients with referrals which was otherwise not always possible. The value of this process was understood.
It is very welcome by all our staff, including the receptionist, the nurse, and myself. And the patients are also very happy … [BCNs] relieve the job from the receptionist and help our GP as well. The GP sometimes has to contact the allied health by ourselves or call the family member, so it is really wonderful, especially reducing the time loading. (GP)
Patients had varying levels of health literacy about chronic disease and of understanding how the health system could assist them. The BCNs had sufficient time to support patients to make appointments and to follow up delayed appointments.
My husband had a cataract surgery. He had been waiting for 3 years in the queue. He had a stroke earlier, and couldn’t see properly as well, … It had been 3 years. … Your navigator went to ask for us the first time and got the answer that we could have the surgery in August. (Patient)
The BCN assisted the practice to achieve its goals and was well suited to assisting patients, enabling continuity of care and patient adherence to treatment plans. This work fitted the values of the practices well and provided welcome extra capacity.
[The BCN is] very well [suited] especially to all the procedures to help the patient to make appointment to see the allied health worker … everything is working well. … If they don’t have this BCN service, they only can rely on either our receptionist or the family member, and usually the family member is so busy they can just do it in 1 month or even later, and sometimes they forget. And then our receptionist will be very busy to do extra work. (GP)
Generally, there was a shared understanding of the role of the BCN in the general practice.
We are very much a team at our practice. Whenever I know that we’ve got the BCN in: I let everyone know … but our team have incorporated her very well. (GP)
Communication is important. … I always tell the patients first that we have this service, and they understand the procedure … they also tell the navigator … what’s the need … and all the staff are aware of this, and they understand how to cope and work with each other. (GP)
However, this understanding could have been improved in some practices and with patients. Some practice staff did not have a clear understanding of the role, and this reduced the number of patients that were referred to the BCN and the success of the BCN placement. In these practices there was some misunderstanding about the role of the BCN being an interpreter or like a receptionist even after initial briefings.
For Arabic [speaking practices], … educating the patient about this project is the most important thing … because they are surprised about this role … but if we have many programs about it and people know about it, if doctors know – it will be more useful than now … and … we have more patients. More people coming to see you to help them because they need this role. (BCN)
For patients, seeing the benefit of the support provided by the BCN was more significant than having a full understanding of the role. While some patients were not sure about the role of the BCN, they understood there was benefit for them as recommended by their GP, who they trusted.
The first time around I was confused because. … You know how there are so many services? … And then when she explained it to me, I go, ‘Okay, I understand. It’s like a carer but in a different aspect’ … I did explain it to my mum. I said, ‘She’s just like a person that can help you out with filling out your forms or when I’m not available.’ And she was really happy with that. (Carer)
The GPs in the medical practices played a clear role in driving the practice staff towards accepting the BCN program. It made more sense to the GPs if the intervention had previously been trialled in their practice.
When they come in, the doctor would explain to them what my role was and what I was doing, so that made it a little bit easier for me and then she would go through what they’d come in for … then I would explain to them again what a Bilingual Community Navigator does. (BCN)
He’s been our doctor, for God, for 30 years. … I respect everything he does. … He recommended that we sit down with her and ask the questions, and everything was fine. … She was on our side. She was helping … (Carer)
The interaction and type of communication between the doctor, reception, and BCN was important to generate work for the BCN.
The front desk staff or the practice manager, … they got patients that needed help on the days I was here. So sometimes they’d ring me and say, ‘Are you coming in today?’ I say, ‘Yeah, but I don’t start till two’. And they said, ‘Oh, ok we’ll reschedule for this patient to come at that time.’ So yeah, they were very helpful. So everyone was on board, everyone knew. (BCN)
The level of flexibility of receptionists with the BCN influenced implementation. The Arabic speaking BCNs had the opportunity to see how practices worked in different locations. By the BCN assisting the reception with their work, they were appreciative of the BCN and they in turn assisted them with their tasks.
This particular [BCN] is absolutely compatible because she compliments our clinical work, she’s really nonclinical, but she has culture, she adds advocacy. Not every … patient will want to use her services, but the ones that do really benefit, and they’re things that are outside our scope … we normally put the BCN in a very sort of inconspicuous spot so she could hear. So we’re really just interacting; the doctor and the patient then as we need to, then address her services; she comes into the consultation. The BCN is always so respectful, patients are happy to have her here, there’s no drama, … that’s how they help, the nurses will do their clinical part, my doctor will do his clinical part and so the BCN just fits in as part of the team. (GP)
The experience of the BCN in interacting with the patients and their familiarity with the role of the general practice facilitated the work. One doctor spoke of the lived experience of one of the BCNs.
She has a lot of experience in terms of just navigating the health system. She herself has chronic medical illnesses. … So she really understood when a person had a diagnosis of diabetes, and she also comes from a background where she understands when there’s very little finances. (GP)
There was a need to better understand each practice patient population and their needs and tailor the approach accordingly. This was especially the case with the Arabic speaking community and the diversity of countries that patients had migrated from. Newly arrived patients had higher needs, lower English proficiency in certain population groups, and were unfamiliar with the Australian health system. More established patients had fewer needs.
In some practices, staff were able to change their routines to support the BCN’s work. For example, the reception staff played a key role in booking patients for the doctor when the BCN was there and reminding the doctor about the BCN.
We are used to arranging the BCN on the day when we have more GPs here, so more GPs can share the service and then you’ll be more effective. They will not only help myself, but my colleagues as well. … all the GPs have the instructions [about the BCN] and they’re all very happy. (GP)
However, in other practices, there was less flexibility to align the work of the GPs with that of the BCNs. Some staff were concerned that some of the BCNs were not utilising their skills enough and having to wait for patient referrals.
The BCNs are sitting for long hours but the amount of work is not enough. Say you’re paying someone A$30 an hour and you stay 5 or 6 hours, it’s A$200–180 and you end up with one patient. (GP)
Where the GP understood the competency of the BCN, the doctor could safely recommend it and have confidence in their ability to complete tasks. However, in some cases the GPs were unsure about just what they were capable of, and this limited their referrals.
… maybe the limitations are that I wasn’t 100% confident of the service. So I did whatever I knew, but I think there was a lot of hidden stuff that I might have … provided it, or engaged in it [more]. (GP)
To assist with understanding the BCN’s role, there could be more clarification of it early on.
Maybe more communication before the BCN placement. For example, we have a short meeting with the head of the reception to tell them our role. … So that they can introduce me to more GP working on that day and also from the university, from your side, you can introduce like maybe just 10 min meeting and then can introduce what’s the role of this. (BCN)
This understanding needed to be extended through community education so that patients were familiar with the role, and this would make it easier for the GP to refer.
Most of the people in the community have never heard about this BCN. So we need to let the population understand this is possible in the community so that this service is possible and then let them be aware that this is something happening overseas already. (GP)
There was some discussion about the similarity of the role of the BCN to others including receptionists, interpreter, and social worker. This raised the need to clarify how the BCN role was different to other roles to enable everyone to engage more fully with it. One BCN explained that they saw the BCN role as complimentary to reception in providing information and support, and improving the health literacy of the patient about navigating the health system.
I think my service is complementary to the receptionist because they don’t make the booking for the patients and also they don’t have time to explain. For example, where is the address of the specialist so the patient … I show them … I can provide some other information like to remind them. … I told them everything like for the day and time … also like some bookings, you need to drink a bottle of water, so I also write it down in Chinese. (BCN)
While the GPs felt that that the BCNs were generally of benefit to many patients, they recognised that some of their patients had sufficient health system literacy to manage on their own.
It was absolutely beneficial. Sometimes less beneficial might be those who were quite aware of the health system, maybe just wanted some support, but you know there is a role for a BCN for sure. (GP)
GPs and BCNs felt it was important to review what groups of patients most needed the BCN assistance and when and how this should be provided to them.
The BCN program was effective in assisting staff and patients. However, the BCNs and GPs discussed how they felt they could have done more to assist patients with the social aspects of their care. There could have been more utilisation of continuity of care and support for social services.
I can do more things; for example how to apply for the home care package. So I think I have some other knowledge about this. But I don’t usually [use this], the patient just comes then to make the booking. (BCN)
With regards to following up patients with chronic disease, monitoring their health plans, and requesting they come in for a check-up, the doctor thought the BCN could have assisted more but did not know about their qualifications/competency to do this.
[Addressing] chronic disease, I don’t think we touched base. … maybe it would be a good idea … they could have done [check-ups]. But I suppose they only had 5 weeks here. But that could have happened, couldn’t it, because they fitted in so well. (GP)
An increased understanding of the role early on with all staff could assist in the expansion and refinement of the role. The unique nature of the role could also be enhanced.
After patients were provided with support through the BCN program, they wanted the certainty the service would be available in the future and at a regular time to ensure their full commitment. This would enhance the adoption and sustainability of the service. Patients were concerned that just as they were getting used to the program, it would cease.
Such service can help us, which is a very good thing. But the problem is … to really help us elder people, such service needs to give us a sense of security on an ongoing basis, a conviction that we can go to them when we have a problem. That makes us happy. For example, make it available on Monday, Tuesday, and Wednesday at the doctor’s clinic … specify a certain period of time. … this service is very helpful for us. I had to say I won the lottery, that I got good luck. (Patient)
Discussion
The present study further strengthened the feasibility and acceptability of the role of BCNs to both staff and patients of Australian general practice. The role of the BCNs was very patient centred, and the type of referrals were appropriate for their needs. However, there were few referrals to social welfare and community-based services except in one practice. This suggests the need for better briefing of GPs and other staff about the role of BCNs and more time to allow information on these services to be compiled by the BCNs. The scope of practice of the BCN role could have been expanded and refined to address more social and chronic care needs of patients, and this may require more training and linkage between practices and community resources. This may be consistent with the role of link workers or navigators in social prescribing also being currently explored in Australia (Baker et al. 2024).
In this study we found that some of the key elements described in NPT (notably coherence and cognitive participation) were in place in practices for effective and sustained implementation of BCNs in general practice (May et al. 2018). GPs, practice staff, and patients and family could all see the potential benefits of the BCNs in providing navigation support to patients, and many were motivated to make the BCN placements successful. However, other elements of NPT were not present (notably collective action and reflexive practice) or were less clearly present. For example, not all GP staff understood the competencies and scope of practice of the BCNs, possibly due to insufficient assessment of the practices’ needs and preparation for the BCN attachments. Without this, in some practices there were too few referrals to the BCNs for the attachments to be viable. This suggests the importance of working with individual practices to identify their patients’ unmet goals and needs, and tailoring the role BCNs may play in addressing them.
The GP’s endorsement of the BCN, as well as the trust of patients in their GPs, were critical to placement success. The styles of teamwork between the GP, practice staff, and BCN and flexibility of organisation in some practices facilitated implementation. This is consistent with our previous research on team innovation in primary care (Harris et al. 2016). However, other practices found it more difficult to align the BCN’s work with their usual practices and needs of their patient population, and referrals were insufficient. For example, some practices were able to proactively arrange for appropriate patient appointments on days and times when the BCN was in the practice, whereas in others this was not possible. Infrequent use made it difficult for them to incorporate into practice routines and appraise the potential benefits to sustaining the program. Although flexibility in organisation helped meet the contextual needs of patients, providers, and practices, clear role designation and strong practice leadership are essential for successful implementation and maintenance. Future funding is also likely to require evidence of performance in service delivery and health outcomes.
BCNs have an emerging role in Australian primary care. Building on the previous pilot study, lessons learned through this study will support the continued implementation of BCNs in primary care settings (Mistry et al. 2023). Our findings from both studies were broadly consistent with a review of research on the implementation of health navigators in primary care. This identified 11 factors that influenced successful implementation and maintenance: patient needs, recruitment and training of navigators, role clarity, clear operating process, adequate resources, strong relationships (internal and external), availability of services, communication, buy-in by end users, and valuing and evaluation of navigator programs (Valaitis et al. 2017). These thus provide a framework for the design and evaluation of future programs.
Beyond primary care, the role of navigators is developing in other areas, notably in Primary Health Network Aged Care Finder services, targeting specific population groups, post hospital care, out of home care for foster children, and cancer care (Chan et al. 2023; Commonwealth of Australia 2024). These are in addition to roles of Aboriginal health workers in healthcare navigation (Rankin et al. 2022). These can be seen as responses to the imbalance between the complexity of health and social care systems and capacity of many groups to navigate them. While health and social care navigators should not be seen as a ‘band aid’ solution to systematic problems, they have the potential to make useful contributions to health system efficiency, outcomes, and health equity. They are, however, fragmented responses with healthcare organisations not taking responsibility for their development.
The sustainability of this project remains uncertain, partly because of changes in the environment that have put more pressure on general practice. As noted in the previous study, there were also limitations in ongoing funding, and this influenced the commitment of practices. Other possible sources of ongoing funding for BCN roles may include Primary Health Networks’ programs focused on specific population groups, management of the needs of registered practice populations under My Medicare, and service navigation under the National Disability Insurance Scheme (NDIS) (National Disability Insurance Scheme Review Panel 2023; Australian Government (Department of Health, Disability and Ageing) 2024). Notably, advocacy for these programs in the US was led by the American Public Health Association and community and religious organisations, because of their importance in addressing health inequities.
Limitations
This study demonstrates the potential role of BCNs in providing navigation assistance to CALD patients in general practice using qualitative research design. We were not able to determine what proportion of potentially suitable patients were referred to the BCNs. The evaluation was conducted with four BCNs, three patients, three carers, and four GPs. More patients and carers could have been involved from the 110 that were assisted. A challenge is sustaining navigator program implementation. Further evaluation research should be conducted and analysis of maintenance and sustainability considerations through funding and broad institutional support.
Data availability
Code lists are available on request from the corresponding author. Our Ethics Committee approval does not allow provision of transcript data to those outside the investigator team and thus access to that data will require submission of a proposal and approval from the Research Ethics Committee. Prior presentation: Australasian Association for Academic Primary Care Conference Sydney Australia August 2024; HSR Conference Brisbane Australia December 2024.
Declaration of funding
This work was supported by a grant from the Central and Eastern Sydney Primary Health Network, Sydney, Australia.
Author contributions
MH, EH, and SKM designed the study and conducted the training of BCNs. CO collected and supervised collection of interview data. All authors contributed to the interpretation of the analysis, discussion of the findings, edited, and commented on the drafts of the paper.
Acknowledgements
Thank you to the doctors, bilingual community navigators, and patients and their carers who contributed to this research.
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