Academic journal article Journal of Healthcare Management

An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System

Academic journal article Journal of Healthcare Management

An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System

Article excerpt

INTRODUCTION

The Affordable Care Act of 2010 holds health systems accountable for patient outcomes such as primary care access, quality of care, and hospital readmissions. Patients with low socioeconomic status are at highest risk of lacking a primary care provider, receiving lower quality of care, and being readmitted to a hospital. These patients have elevated risks of all-cause readmissions and death after discharge (Baker et al., 2002; Elixhauser, Au, & Podulka, 2011; Foraker et al., 2011; Rodriguez-Artalejo et al., 2006). To improve care outcomes, hospitals must address socioeconomic and behavioral risk factors that occur in their patients' homes and their communities.

A study of 11 Medicare Coordinated Care Demonstration programs attempted to identify the elements of successful programs and found that care coordination can reduce the need for hospitalization between 8% and 33% among high-risk patients in the Medicare population. One distinguishing element was the amount of face-to-face contact between care coordinators and patients. Successful programs included frequent in-person contacts-at least once per month, either in the patient's home or at the physician's office. Another distinguishing element was the presence of a strong, evidence-based patient education intervention. Successful programs taught patients about their diseases, including symptoms and self-care. However, the most distinguishing feature found was an emphasis on comprehensive and timely transitions from hospitals. Care coordinators who communicated with hospital staff during admission about the patient's current diagnoses, medications, and relevant psychosocial issues ensured that patients were not lost during transitions of care (Brown, Peikes, Peterson, Schore, & Razafindrakoto, 2012).

Community health workers (CHWs) are trained laypeople who play an important role in the coordination of high-risk patients by providing support that is consistent with each patient's values and needs (Israel, 1985). An intention-to-treat analysis (Kangovi et al., 2014) found that patients who received individual intervention action plans from CHWs were more likely to obtain timely post-hospital primary care (60.0% vs. 47.9%; p = .02; adjusted odds ratio [OR] 1.52; 95% confidence interval [CI], 1.03-2.23) and to self-report high-quality discharge communication (91.3% vs. 78.7%; p = .002; adjusted OR 2.94; 95% CI, 1.5-5.8). Similar proportions of patients in both arms experienced at least one 30-day readmission; however, intervention patients were less likely to have multiple 30-day readmissions (2.3% vs. 5.5%; p = 0.08; adjusted OR 0.40; 95% CI, 0.14-1.06). Patient-centered intervention improved access to primary care and quality of discharge (Israel, 1985).

Numerous studies have investigated the role of discharge navigators and how they relate to a reduction in hospital readmission rate following heart failure. A review of 17 studies (Schell, 2014) found that discharge navigation is clearly beneficial in reducing hospital readmission rates for patients with heart failure. In a randomized controlled trial (Jack et al., 2009), participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 369) (0.314 vs. 0.451 visit per month; incidence rate ratio 0.695; 95% CI, 0.515-0.937; p = .009). The intervention was most effective among participants with hospital utilization in the six months before index admission (p = .014).

A randomized controlled trial (Balaban et al., 2017) showed that using CHWs as patient navigators to high-risk general medicine patients for 30 days showed a 0.21 reduction in hospital-based encounters: 180 days for patients > 60 years of age (p = .038). However, younger navigated patients (<60 years) showed a cumulative increase of 0.79 hospital-based encounters (31.7, p = .017) per patient at 180 days. The cumulative difference in hospital admissions at 180 days was an increase of 41. …

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