Project ID: 2.c.i
Project Name:
Navigation Program
Project Description:
Development of community-based health navigation services
Project Chairs:
John Migliore, Bassett Medical Center
Bonnie Post, Schoharie County Office of Community Services
Stephanie Lao, Catholic Charities Care Coordinator Services
Deanna Charles, Catholic Charities of Herkimer County
Objective:
To develop a community based health navigation service to assist patients to access health care services efficiently.
Rationale and Relationship to Other Projects:
Health literacy, community values, language barriers, and lack of engagement with community health care services can result in avoidable use of hospital services. People who do not understand how to access and use the health care system cannot be expected to use it effectively. This community resource is not necessarily a licensed health care provider, but a person who has been trained and resourced to understand the community care system and how to access that system including, e.g., assisting patients with appointments and obtaining community services. They may be available face to face, telephonically or through on line services and will have access to language services as well as low literacy educational materials.
This service may be developed as an extension project to an existing Health Home program to assist with outreach, engagement and retention in Health Home services. Community navigators may follow a patient longitudinally to ensure the patient is able to access health care and other needed services and is gaining self-confidence in managing his/her health.
(Note: While this project and Project 2.d.i both utilize community-based health navigators, the focus of the two projects is very different. Project 2.d.i is focused on persons not utilizing the health care system and working to engage and activate them to utilize the system to see primary and preventive care services. This project is focused on persons utilizing the system but doing it ineffectively or inappropriately. The navigation service here assists these person to access the system effectively and appropriately by providing bridge support until the patient has the self-confidence to manage his/her own health.)
Core Components:
The performing provider system will undertake the following components of this program:
- The need for this program will be identified through a regional or service area needs assessment. Need may be based on identified language, cultural or health literacy barriers to understanding the health care delivery system, particularly as it transforms and old patterns of care are expected to change. Hot spots of service need may be identified.
- Where need is identified, a collaborating program oversight group of medical and behavioral health practitioners and providers and community nursing and social support services will develop a community care resource guide to assist the community resource person and to ensure compliance with protocols. Training protocols will need to be developed and implemented. (Training for community health workers may serve as guidance, despite a different community role.)
- Recruitment for the community navigators would ideally be done from the residents in the targeted area to ensure community familiarity. In addition, PPSs should not attempt to “recreate the wheel”. Resourcing for the community navigators will need to be established and could include placement in an ED waiting area, community health center, community meeting center, etc. Telephonic and IT resources including a chat line will need additional resourcing to increase community access to the service.
- Community navigators will need access to non-clinical resources such as transportation and housing services to remove patient barriers to accessing medical and behavioral health care.
- For community navigators who are following patients longitudinally, case loads and discharge processes will need to be established to ensure efficiency in the system.
- Wide marketing of the resource in the community will be done.
- Utilization measures that will be based on the community assessment will need to be developed, collected and reported on to the program oversight committee to understand the effectiveness of the program and changes that are needed.
- Consistent with the need in the community, the program must demonstrate a clear cultural competence and willingness to engage Medicaid members in the design and implementation of system transformation including addressing issues of health disparities.