Emails & Telephones
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• Dr. Grace Liu, Post-Doctoral Fellow, St. John’s Rehab Research Program, 416-226-6780, grace.liu2@sunnybrook.ca
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• Dr. Kristina Kokorelias, Senior Academic Program Coordinator and Associate Scientist, Sinai Health and the University Health Network, 416-586-4800 ext 4374, Kristina.Kokorelias@sinaihealth.ca
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• Amanda Knoepfli, Manager – Social Work, Sprint Senior Care, 416-481-6411, Amanda.Knoepfli@sprintseniorcare.org
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• Tracey DasGupta, Director of Interprofessional Practice, Sunnybrook Health Sciences Centre, 416 480 6100, ext. 63917, Tracey.DasGupta@sunnybrook.ca
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• Naomi Ziegler, Vice President – Client Services, Sprint Senior Care, 416-481-6411, naomi.ziegler@sprintseniorcare.org
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• Dr. Sara Guilcher, Associate Professor, University of Toronto, 416-946-7020, sara.guilcher@utoronto.ca
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• Dr. Sander Hitzig, Director and Senior Scientist, St. John’s Rehab Research Program, 416-226-6780 x57177, sander.hitzig@sunnybrook.ca
Introduction
The concept of patient navigation (PN) was first pioneered by Dr. Harold Freeman during the late 1980s for oncology patients (Freeman, Reference Freeman2013) to address disparities due to economic, social, and cultural factors that influenced access to timely diagnosis and treatment (Freeman & Rodriguez, Reference Freeman and Rodriguez2011). Because people with chronic diseases have increased morbidity and access to more health care resources than those without (Health Council of Canada, 2011), PN programs are increasingly being used to help people with chronic diseases navigate and access health services (McBrien, et al., Reference McBrien, Ivers, Barnieh, Bailey, Lorenzetti, Nicholas, Tonelli, Hemmelgarn, Lewanczuk, Edwards, Braun and Manns2018). In some cases, these PN programs are delivered by individuals with a professional background (e.g. registered nurse or social worker), while others may use trained lay or peer navigators who have lived experience navigating through the system (Freeman, Reference Freeman2013; Carter et al., Reference Carter, Valaitis, Lam, Feather, Nicholl and Cleghorn2018). In the literature, there are different roles, functions, and backgrounds of patient navigators (Kelly, et al., Reference Kelly, Doucet and Luke2019; Kokorelias, Shiers-Hanley, Rios et al., Reference Kokorelias, Shiers-Hanley, Rios, Knoepfli and Hitzig2021).
Although there are a variety of PN programs in the existing literature, McBrien et al. (Reference McBrien, Ivers, Barnieh, Bailey, Lorenzetti, Nicholas, Tonelli, Hemmelgarn, Lewanczuk, Edwards, Braun and Manns2018) defined a patient navigator as “a person with or without a health care-related background that engages with patients on an individual basis to determine barriers to accessing care or following recommended guidelines, and provides information relevant to patients’ specific circumstances to facilitate self-management and access to care” (p. 24). However, there are variations in the design and delivery of PN programs, which may make it challenging to adopt PN interventions in new contexts (Desveaux et al., Reference Desveaux, McBrien, Barnieh and Ivers2019). Because PN programs for older adults with complex care needs are not well established, particularly in a hospital setting, there have been inconsistencies in understanding the patient navigator role among health care professionals and administrators in hospital and in the community (Kokorelias, Posa, et al., Reference Kokorelias, Posa, DasGupta, Ziegler and Hitzig2021).
PN programs have become more popular and applied in different ways for various populations (McBrien et al., Reference McBrien, Ivers, Barnieh, Bailey, Lorenzetti, Nicholas, Tonelli, Hemmelgarn, Lewanczuk, Edwards, Braun and Manns2018), but there are several questions regarding the most appropriate service types and the patient groups that benefit most from these programs. For instance, a scoping review of PN programs for adults with complex needs, Kokorelias, Shiers-Hanley, Rios et al, Reference Kokorelias, Posa, DasGupta, Ziegler and Hitzig2021 concluded that there was a need to determine the most appropriate patient navigator type and delivery method best suited for a given setting and target population. Furthermore, the scoping review identified a need for more guidance on best practices for implementation of PN programs. In addition, the duration and frequency of a patient navigator’s involvement was often unspecified and the characteristics of the intended population were not reported in most of the articles. As such, additional patient characteristics should be captured to better understand differences in PN programs, roles, interventions, and associated outcomes for future implementation considerations. Because this innovative model of care is relatively new, further research is needed to demonstrate the impact of PN programs on all populations (Reid et al., Reference Reid, Doucet, Luke, Azar and Horsman2019; Kokorelias, Shiers-Hanley, Rios et al., Reference Kokorelias, Shiers-Hanley, Rios, Knoepfli and Hitzig2021) and to explore patient navigator caseloads and/or cost-effectiveness across the disease continuum in a variety of health care settings (McBrien et al., Reference McBrien, Ivers, Barnieh, Bailey, Lorenzetti, Nicholas, Tonelli, Hemmelgarn, Lewanczuk, Edwards, Braun and Manns2018; Reid et al., Reference Reid, Doucet, Luke, Azar and Horsman2019; Kokorelias, Shiers-Hanley, Li et al., Reference Kokorelias, Shiers-Hanley, Li and Hitzig2022).
Gaps in discharging patients from hospital to home results in delayed discharges or alternative level of care (Brown & Menec, Reference Brown and Menec2021). In this article, discharge planning is defined as “the development of an individualized discharge plan for a patient prior to them leaving the hospital for home” (p. 6) (Gonçalves-Bradley et al., Reference Gonçalves-Bradley, Lannin, Clemson, Cameron and Shepperd2016). The term “alternate level of care” (ALC) is used in Canada to identify hospital beds which are occupied by patients who could have been cared for elsewhere due to a mismatch between the patients’ care needs and the services provided in that care setting (Canadian Institute for Health Information, 2016). Because there is a need to reduce the number emergency department visits (Jehloh et al., Reference Jehloh, Songwathana and Sae-Sia2022) and ALC rates, transitional care interventions should be directed at cross-sectoral initiatives by linking patients to appropriate community-based services (Cadel et al., Reference Cadel, Guilcher, Kokorelias, Sutherland, Glasby, Kiran and Kuluski2021). The presence of a patient navigator can facilitate communication between patients and providers (Schleyer et al., Reference Schleyer, Woan, Johnson, Strizich, Bann and Stack2015), and connect with patients and families/caregivers while they are in the hospital and also providing post-discharge follow-up once they are back home in the community (Kokorelias, Singh, et al., Reference Kokorelias, Singh, Posa and Hitzig2022).
Recently, there have been efforts to promote transitional care services which are similar to the services provided by patient navigators for the older adult population, with some evidence demonstrating positive outcomes (Lee et al., Reference Lee, Yang and Cho2022). For instance, a systematic review on transitional care interventions from hospital to home found various strategies were employed to improve the health outcomes of frail older adults (Lee et al., Reference Lee, Yang and Cho2022). However, the evidence on the intervention effectiveness was scarce, and inconclusive for frail older adults (Lee et al., Reference Lee, Yang and Cho2022). Because interventions were different in terms of settings, providers, and follow-up duration, there are no established best-practice guidelines or consistent evidence on the most appropriate transitional care model for frail older adults (Lee et al., Reference Lee, Yang and Cho2022).
In another systematic review, Parker et al. (Reference Parker, Hickman, Phillips and Ferguson2020) also revealed a lack of transitional care interventions to support older people living with dementia and their caregivers. Future studies must consider the most appropriate provider(s), and intervention(s), including duration and intensity, to provide the evidence to support the use of patient navigators for older adults to support them in care transitions and discharge planning. It is important to support at-risk older adults transitioning from hospital to home (Provencher et al., Reference Provencher, Clemson, Wales, Cameron, Gitlin, Grenier and Lannin2020) and to develop comprehensive policy strategies to reduce the burden of navigating health and social services (Funk, Reference Funk2019).
Background
At our clinical site, a large metropolitan hospital in partnership with a community agency, a new pilot PN program was introduced in the Fall of 2019 to improve the continuity of care across care transitions for older adult patients with complex care needs. In this study, the patient navigator is a social worker, called a ‘Community Transitional Lead’, who is employed by a community-agency partner and is embedded in the hospital to coordinate care plans and assist patients and families/caregivers as they transition from hospital to community for up to 90 days post-hospital discharge. In this article, the term ‘caregivers’ is used and refers usually to a family member or friend, who supports the patient in decision-making (i.e., coordinating care) or assists in daily needs or instrumental activities of daily living.
This PN program was evaluated in two phases. The first phase of this project focused on qualitative research methods by interviewing patients and health care professionals, including acute and community care providers in real time during the initial implementation of the PN program. This evaluation phase revealed that the patient navigator facilitated hospital-to-home transitions (Kokorelias, Posa et al., Reference Kokorelias, Posa, DasGupta, Ziegler and Hitzig2021) and fostered a positive patient experience, leading to high levels of satisfaction (Kokorelias, Gould et al., Reference Kokorelias, Gould, Ziegler, Landau, DasGupta, Knoepfli, Cass and Hitzig2021). However, there is a need for additional quantitative evidence (phase two) to characterize the types of patients being referred to the PN program, the scope of the patient navigator’s practice, and program outcomes (Kokorelias, Shiers-Hanley, Rios et al., Reference Kokorelias, Shiers-Hanley, Rios, Knoepfli and Hitzig2021).
Objective
The objective of this study (phase two) was to describe a PN program designed for older adults with complex care needs receiving care in a hospital setting. Specifically, we aimed to explore the characteristics of patients referred to and supported by a patient navigator (i.e., socio-demographics, case-mix grouping, co-morbidities, referral source and reasons), determine the scope of practice of a navigator (i.e., types of interventions, service duration, and post-discharge location), and evaluate the impact of the PN program on outcomes (i.e., hospital length of stay, delayed discharge or ALC). Study outcomes are expected to provide greater clarity about PN programs in a hospital setting, which can provide needed evidence to guide decision makers on future implementation considerations.
Methodology
Study design
The present study used a retrospective cohort observational design to describe the PN program for older adults with complex care needs, including the types of patients served, the patient navigator’s scope of practice, and program outcomes. Our work was guided by the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) statement (Enhancing the Quality and Transparency of Health Research Network, 2023), where we extracted hospital-level data from a set of older adult patients with complex care needs who were referred to a PN program between November 2019 and November 2021 in Southern Ontario, Canada. See Supplementary Material ‘STROBE Statement – Checklist of items that should be included in reports of cohort studies’.
Setting
The PN program consisted of a single patient navigator employed by the community agency who operated out of the acute care hospital to support patients referred by hospital staff during their hospital stay or emergency visit, or by primary care, home care or community providers. Upon referral, the patient navigator would assess the patients’ needs and support them for up to 90 days. Ethics approval for this study was obtained by the research ethics boards at the Sunnybrook Health Sciences Centre [REB 1598] and SPRINT Senior Care.
Participants
All patients referred to the PN program were eligible for inclusion. The criteria for referral were older adults who had a visit to the hospital’s emergency department, inpatient units, associated hospital sites, or from the community where the patient resided within the City of Toronto. For the data analysis, the inclusion criteria were first-time referred older adult patients who received PN service for more than three days. Because interactions under three days were considered as consults, these cases were excluded from analysis.
Measures
The patient navigator used a clinical tracking sheet to detail key information, including referral reasons, service or interventions provided, and post-discharge location. The investigation team used the patients’ Medical Record Number (MRN; where available) to extract hospital administrative data from the hospital’s Decision Support Discharge Abstract Database (DAD) System. This included information on the inpatient acute care admission, actual length of stay, case-mix groupings, and co-morbid conditions (including most responsible health condition, primary and secondary diagnoses) over the 90-day period.
The Canadian Institute for Health Information’s case-mix grouping methodology is designed to aggregate acute care inpatients with clinical and resource-utilization characteristics, and categorizes patients into similar statistically and clinically homogeneous groups by considering age, co-morbidity level, and interventions (Canadian Institute for Health Information, 2022). Because there are many case-mix groupings, the cases were coded into five main categories (i.e., medical, cardiology, respiratory, cognitive, orthopedics, and other conditions). The other administrative information included patients who were identified as ALC.
Data collection
All of the sources of data from the participants were those routinely collected as part of standard clinical care. As such, informed consent was waived because the data were considered a secondary use of information not specifically intended for research, and was extracted retrospectively from the various data sources. Therefore, a waiver of consent was provided for this study for this chart component, while the qualitative component did include an informed consent process, and is detailed elsewhere (Kokorelias, Singh et al., Reference Kokorelias, Singh, Posa and Hitzig2022). The data extracted from the patient navigator’s clinical tracking sheet and hospital decision support system were (1) patient socio-demographics profile (i.e. chronological age, gender, and postal code) and case-mix grouping and co-morbidities; (2) referral source and reasons; (3) PN service including types of interventions, duration and post-discharge location; and (4) impact of PN program on patient outcomes (i.e., hospital length of stay, ALC).
Analysis
Data were screened and reviewed by the first author (GL) and senior responsible author (SLH). Open-ended descriptive comments detailing reasons and PN interventions were classified and coded by the senior responsible author and verified by the patient navigator (AK) who collected the data. The patients’ postal codes were mapped to the geographic region using the City of Toronto’s Neighbourhood Profile Data (2023), which provided the neighborhoods where the patients lived. Frequencies and descriptive statistics were determined, including range, mean, median, interquartile range, and standard deviation.
Results
Of the 176 cases referred to the patient navigator between November 2019 to November 2021, 28 were deemed not appropriate for PN service (i.e., patient declined, or deceased), 53 received consults (service length of three days or less), and five were loss to follow-up (i.e., unable to be reached despite multiple attempts by the patient navigator to contact the patients or families for follow-up). It should be noted that one MRN was missing for one patient and could not be retrieved from the hospital’s administrative system. Additionally, data were missing for 16% (n = 14) of patients as the administrative data from the hospital’s decision support database system could not be matched. The data were missing because the patients did not have an inpatient acute care admission to the hospital, were referred from the community or emergency, or were located in an inpatient rehabilitation care setting.
Descriptive data
Of the 90 patients who were assigned to the patient navigator’s caseload, the mean age was 79 (unknown = 3), which ranged from 55 to 95 years of age (IQR = 15.5, median = 79, SD = 9.9). The gender ratio was 54% female (n = 49) and 46% male (n = 41). Upon receiving a referral, the patient navigator would then interview the patients or families/caregivers to identify the patients’ needs. The patient navigator would also ask whether their families/caregivers were stressed. Based on the data collected by the patient navigator, approximately half of the patients (49%, n = 44) had at least one family/caregiver. For this subgroup of patients with a family/caregiver, 52% (n = 23) of these families/caregivers identified they were stressed, at risk of burn-out or experiencing burn-out. In 46% of the cases (n = 41), the patients were previously connected with a community agency where the patient navigator worked.
Based on the data from the hospital’s administrative decision-support DAD system, postal codes were available for 81% (n = 73) of the cases and missing for the other 17 cases. There were 15 postal codes missing due to unmatched MRNs. For one of the cases, the postal code was inaccurate, and in another case, the patient did not live in the City of Toronto. Figure 1 details the map of the geographic area served within the City of Toronto. Most patients (96%, n = 70) lived within a 10-km radius of the hospital and 64% (n = 47) lived in four distinct neighbourhoods.
Map of the geographic area served within the city of Toronto.
Case-mix groups and co-morbid conditions
Out of the 90 cases admitted to the patient navigator’s caseload, 83% (n = 75) had an inpatient visit at our hospital with an associated case-mix grouping. The top five case-mix grouping categories were: (1) general medicine (38%, n = 29), (2) cardiology (20%, n = 15), (3) respiratory (11%, n = 8), (4) cognition (11%, n = 8), (5) orthopedics (8%, n = 6), and other (12%, n = 9) (see Table 1). Co-morbid conditions, as well as primary and secondary diagnosis over the past 90 days, were also captured. The majority of patients had various underlying co-morbid conditions where 99% (n = 74) had medical-related issues, 41% (n = 31) had cognitive-related issues (e.g. delirium, or dementia), 32% (n = 24) had musculoskeletal-related issues, and 25% (n = 19) had mental health issues (e.g. depressive episode, bipolar, or behavioral disorders).
Case-mix grouping categories and examples
* Based on the available case-mix groupings collected, 83% (n = 75) of patients were captured, in which 15 case-mix groupings were missing.
Referral source and reasons
Most referrals were from the inpatient hospital’s acute care (67%, n = 60). Figure 2 provides a breakdown of referral source. It should be noted that there could be one or more reasons for referrals to the PN program. The two top reasons for referral were the need for connection to community services (59%, n = 53) and housing related matters (44%, n = 40). Forty-two per cent (n = 38) of referrals were for discharge planning and 24% (n = 22) for provider connection. In additionally, social concerns (23%, n = 21) and caregiver issues (17%, n = 15) were also reasons for PN program engagement. See Table 2 for the full list of reasons for PN service referral and PN interventions with examples.
Breakdown of referral source (by percentage) (N = 90).
Reasons for patient navigation service referral and interventions with examples
PN interventions
Upon receipt of the referral, the patient navigator was able to contact the patient or families/caregivers on the same day (30%, n = 27), within 7 days (52%, n = 47), from 8 to 14 days (8%, n = 7) or ≥15 days (6%, n = 5). Data were missing for 4% of the cases (n = 4). The average PN service length was 74 days (IQR = 83, median = 49 days, SD = 69.3) ranging from 5 to 344 days.
In terms of PN services provided to the 90 patients, which may have included one or more interventions per patient, the top interventions were service connection making referals to community services (n = 59; 66%), assist with discharge planning (n = 55; 61%), and connect to providers (including physicians, allied health, and/or mental health) (n = 53; 59%). The patient navigator supported patients who were socially isolated (n = 10; 11%), and caregivers who were stressed, at risk of burn-out or experiencing burn-out (n = 28; 31%). The patient navigator discussed housing alternatives or supported patients transitioning to another facility (n = 28; 31%). The patient navigator provided support in instrumental activities of daily living (n = 14; 16%) and facilitated or referred patients/families to financial or legal services (n = 14; 16%). The patient navigator was also involved in end-of-life planning by supporting advanced care, liaising with palliative care providers and providing grief/bereavement counselling (n = 12; 13%). See Figure 3 that outlines PN referrals and PN interventions.
Comparing patient navigation referrals and interventions (by percentage) (N = 90).
Hospital inpatient acute care admission
Based on the hospital inpatient acute care admission, the average length of stay (LOS) was 16.8 days (n = 75; SD = 21.8) which ranged from 1 to 158 days (IQR = 10, median = 12). Fifty-six per cent (n = 42) of the cases were identified as ALC, where the average ALC was 13.0 days (SD = 24.7) and ranged from 1 to 150 days (IQR = 12, median = 4.5).
PN discharged location
Upon discharge from PN program, most patients were either discharged home or to a supportive housing/retirement home setting (66%, n = 59). For the rest of the patients, they were discharged to reactivation care (12%, n = 11), palliative care (5%, n = 4), long-term care (3%, n = 3), inpatient rehabilitation hospital (2%, n = 2), or acute care hospital (1%, n = 1). Nine per cent (n = 8) of the patients were deceased. Despite multiple attempts by the patient navigator to contact the patients or families to provide follow-up, the discharged location was unknown in 2% (n = 2) of the cases.
Discussion
Currently, there are no best-practice guidelines for designing a PN program for older adults with complex needs when transitioning from hospital to home (Kokorelias, DasGupta et al., Reference Kokorelias, DasGupta and Hitzig2022). PN programs have been introduced as a model of care to help improve hospital to home transitions and to better integrate care across care environments (Kokorelias, DasGupta et al., Reference Kokorelias, DasGupta and Hitzig2022). The present study exploring a PN program for older adults with complex care needs provides important insights into the types of patients being supported by this program in a hospital setting. Specifically, we described the characteristics of patients referred to and supported by a patient navigator, the scope of practice including referral reasons and interventions provided, service duration, and post-discharge location.
Although there have been multicomponent and multidisciplinary transitional care models implemented over the last several decades (Naylor, Reference Naylor2002; Naylor & Keating, Reference Naylor and Keating2008; Toles et al., Reference Toles, Abbott, Hirschman and Naylor2012), as well as navigation models for the older adult population, there is a lack of consensus on the desired characteristics and effectiveness of the patient navigator’s role (Manderson et al., Reference Manderson, McMurray, Piraino and Stolee2012). With this in mind, further research is needed to understand the effects of various roles that different health professionals can serve in navigator roles, as well as the types of interventions they can provide for older adults (Morkisch et al., Reference Morkisch, Upegui-Arango, Cardona, van den Heuvel, Rimmele, Sieber and Freiberger2020). Most PN programs are provided by nurses, with fewer using other allied health professionals such as social workers (Manderson et al., Reference Manderson, McMurray, Piraino and Stolee2012). This study provides preliminary evidence of a community social worker working as a patient navigator in a hospital setting.
The evidence from this study fills an important knowledge gap to better understand the patient navigator role and the potential scope of practice for a PN program implemented for older adults with complex care needs in a hospital setting, including the patient characteristics. In terms of patient characteristics, the majority of patients were in their seventies or older and were from neighborhoods within proximity to the hospital, in which many were connected to the community agency running the PN service for adults (59 years of age or over). Many patients were referred from inpatient hospital settings due to acute medical episodes with underlying co-morbid conditions (i.e. medical, cognitive, musculoskeletal, and/or mental health). Given the complexity of health care needs across the participants, the PN program appears to have targeted the intended population.
Because the patient navigator was embedded within the hospital’s care teams, the patient navigator was able to liaise between the hospital and community service agencies and/or providers to coordinate discharge care plans. Another advantage of having the patient navigator situated within the hospital was the rapid response rate of first contact where the patient navigator involved with the patients and connected with their families/caregivers quickly. Qualitative findings from the phase one study showed that the patient navigator provided immediate consultation to help the health care professionals in the hospital who were seeking for information on community services (Kokorelias, Posa et al., Reference Kokorelias, Posa, DasGupta, Ziegler and Hitzig2021). The current study (phase two) highlights that the patient navigator played an important role in supporting discharge planning between the hospital and community service agencies and/or providers. The role of the patient navigator appeared to be important in transitional care and maintaining consistency in care between hospital and community dwelling (Kokorelias, Singh et al., Reference Kokorelias, Singh, Posa and Hitzig2022). Future PN programs should consider increasing efforts to connect with families/caregivers and health care professionals as soon as they are admitted to the hospital and for as long as needed (Kokorelias, Singh et al., Reference Kokorelias, Singh, Posa and Hitzig2022).
In terms of the patient navigator’s scope of practice, the top interventions were service and provider connections, providing referrals to community service agencies and/or providers, both of which helped patients and their families/caregivers navigate the health care and social systems. In many instances, the patient navigator connected patients to a variety of community services based on their social needs (e.g. transportation, meals, day programs, and personal support worker), and linked to them to publicly funded health services based on their health needs (e.g., physicians, providers in home and community care, mental health, and addiction services). This aligns with the scoping review by Valaitis et al. (Reference Valaitis, Carter, Lam, Nicholl, Feather and Cleghorn2017), where the goals of PN programs are to link patients to primary care services, specialists care, and community-based health and social services, and provide more holistic patient-centred. Because there are barriers to community participation among older adults transitioning from hospital to home (Gough et al., Reference Gough, Baker, Weber, Lewis, Barr, Maeder and Goerge2021), the patient navigator can help identify and resolve patient barriers to care (Valaitis et al., Reference Valaitis, Carter, Lam, Nicholl, Feather and Cleghorn2017).
The current study took place during the COVID-19 pandemic period; therefore, it was difficult to determine the extent of families/caregivers’ needs. In Ontario, 25% of caregivers reported that their responsibilities became more difficult, as they took on additional work normally provided by a personal support worker or nurse (The Ontario Caregiver Organization Spotlight Report, 2022). Moreover, one-third of caregivers reported challenges in accessing services and one-fourth of caregivers did not know what they needed (The Ontario Caregiver Organization Spotlight Report, 2022). The PN program can fill this gap. For example, when patients were not sure what they need, the patient navigator could assess and address changing needs and recommend appropriate service (Kokorelias, Singh et al., Reference Kokorelias, Singh, Posa and Hitzig2022). Indeed, a key goal of the PN program is to help patients and their families/caregivers connect to and access available services (Kokorelias, Singh et al., Reference Kokorelias, Singh, Posa and Hitzig2022), including providers and navigating various community services.
In addition to providing navigation assistance, the patient navigator’s scope of practice also included psychosocial support to the patients and their families/caregivers. The navigator provided interventions to support the social needs of patients and caregivers by providing emotional support and/or referring families/caregivers to peer support programs. As showcased in this study, the issues of caregiver support need to be considered in the patient navigator’s initiatives, especially given the essential role of family members/caregivers in supporting the care of individuals with dementia (Kokorelias, Markoulakis, et al., Reference Kokorelias, Markoulakis and Hitzig2023). However, it is unclear if the need for caregiver support or reports of caregiver burden were based on the clinical judgment of the patient navigator or explicitly requested by the caregivers themselves because the clinical notes were not explicit about these details. Regardless, it is important to understand what is important to older adults and support their families/caregivers when they are stressed (Kokorelias, Singh et al., Reference Kokorelias, Singh, Posa and Hitzig2022) and what matters to older adults during and after transitions between hospital and home (Nilsen et al., Reference Nilsen, Hollister, Soderhamn and Dale2022). The patient navigator can play a critical role in supporting patients and their families/caregivers; however, further research is recommended to better understand the needs of the patients and families and to prevent them from being stressed or experience burn-out.
The patient navigator in this study supported many patients and their families/caregivers in managing instrumental activities of daily living which were within their scope of practice. However, in some cases, the patient navigator provided interventions beyond the originally intended scope, in which the patient navigator facilitated the patients and their families/caregivers to pay their bills, helped them apply for grants/subsidies for low-income patients, or liaise with the Power of Attorney/Public Guardian and Trustee. For people with complex care needs, the integration of health and social care is needed to address social determinants of health, beyond the traditional health care services (Kuluski et al., Reference Kuluski, Ho, Kaur Hans and Nelson2017). As such, this pilot PN program provides preliminary evidence that effective collaborations between health care organizations and community-based organizations are essential to address unmet social needs (Ruiz Escobar et al., Reference Ruiz Escobar, Pathak and Blanchard2021).
Housing alternatives were a significant reason for referral and intervention to PN program in this study. Because 56% of the patients were designated as ALC patients, this finding may be related to the complexity of patient needs and/or may have been impacted and exacerbated by the COVID-19 pandemic. During the pandemic, many health and social care services were disrupted. For example, approximately half of all households in Canada who used home care services reported unmet needs in 2021 (Statistics Canada, 2022). Given the disruption of home and community services during the COVID-pandemic, the need for social and housing supports was not surprising. Due to the challenges faced by hospital and community staff in caring for older adults with housing needs, a PN program with a focus on housing may provide support for older adults (Kokorelias, Sheppard et al., Reference Kokorelias, Sheppard and Hitzig2023).
With the support of the patient navigator, 66% of the cases in this study returned home or to a supportive housing/retirement home setting upon discharge from the PN program. For patients who transitioned from hospital to another facility, the patient navigator also supported them, while they were being transferred to a reactivation care, long-term care, or inpatient rehabilitation setting. In this study, the patient navigator appeared to play an important role in supporting patients across the health care continuum. Therefore, it may be possible that without the patient navigator to facilitate discharge plans, patients may have remained longer in acute care hospital. However, further evidence is required to evaluate such outcomes of PN programs.
Implications for practice
More research that focuses on different patient navigator backgrounds and experience is needed to determine the best characteristics of a patient navigator for specific patient populations (Kokorelias, Shiers-Hanley, Rios et al., Reference Kokorelias, Shiers-Hanley, Rios, Knoepfli and Hitzig2021). This research described the scope of practice of a patient navigator who is a community social worker for older adults in a hospital. The patient navigator supported older adults with complex care needs during transitions of care by connecting them to community services or providers, addressing social and caregiver concerns, providing assistance for instrumental activities of daily living, facilitating on financial/legal or housing issues and end-of-life care decisions. Because this social worker is affiliated with a community agency, this patient navigator role and care model approach appeared to be ideal in assisting older adults with complex needs transition from hospital to home. Although this research contributed to advance PN care models, further work is needed to determine the impact of patient navigators’ experiences and educational background on outcomes (Kokorelias, DasGupta et al., Reference Kokorelias, DasGupta and Hitzig2022).
Implications for decision makers
Using the hospital administrative database, we obtained data on the case-mix and co-morbidities, and explored the outcomes (i.e., LOS and ALC rate) of older adults who were supported by a patient navigator. Because there was no comparison group, we cannot determine the impact of the PN program on outcomes (i.e., hospital readmissions, LOS, ALC). The high ALC rate was expected given the complex needs of older adults. As per Ontario Health’s ALC Leading Practices Working Group, 80% of Ontario’s ALC designations were attributed to older adults (65+) (Ontario Health, 2021). The causes of delayed transitions are often identified as capacity issues in other parts of the health care system, such as “not enough home care” and “not enough long-term care beds” (Ontario Health, 2021). More research is needed to address integrated care for hospital to home transitions (Brown & Menec, Reference Brown and Menec2021) and improve delayed discharges from a hospital setting (Cadel et al., Reference Cadel, Guilcher, Kokorelias, Sutherland, Glasby, Kiran and Kuluski2021), particularly for older adults with complex needs (Le Berre et al., Reference Le Berre, Maimon, Sourial, Guériton and Vedel2017).
Study limitations
In this study, although the use of data from both the patient navigator’s clinical notes and the hospital administrative database provided several important insights, there were some gaps. From the patient navigator’s clinical notes, the scope of practice and duration of PN service was captured but the intensity, frequency and cost-effectiveness were not collected. In future studies, stronger reporting standards is suggested to replicate and better understand the benefits and effectiveness of this PN program. Becasue this phase of the study (phase two) was based on describing the patient navigator’s clinical notes, we were unable to correlate the findings to the initial phase (phase one). For example, we were unable to determine which interventions were most beneficial from the patients’ perspective from the clinical notes. From the clinical notes, it was unclear whether it was the patients or families/caregivers which reported caregiver stress, or perhaps it was identified based on the navigator’s assessment and clinical judgment.
In using the hospital’s administrative decision-support DAD system, it was challenging to match the patients based on the MRN and to classify the high number of case-mix codes, including most responsible conditions and co-morbidities used to classify the physical, cognitive, and mental health needs of patients. We explored program outcomes such as hospital LOS and ALC; however, there are various factors that may have influenced these measures. Because we were unable to identify a comparative cohort group due to the small sample size, the impact of the program cannot be determined.
Because this study only provides a descriptive account of the PN program, future studies should attempt to find an appropriate comparison group to better evaluate the impact of the PN program. We recommend the need to include LOS and to capture the ALC rate and reason(s) for future evaluation with a comparison group to demonstrate the impact of the PN program. Further research is recommended to determine whether the PN program can impact readmission and ALC rates and address integrated care for hospital to home transitions.
Conclusion
The findings in this research provide a better understanding of a PN program to support older adults with complex care needs transition from hospital to home, including the patient characteristics, scope of practice, and program outcomes. The patient navigator played an active role working onsite with the hospital teams to help older adult patients and their families/caregivers in coordinating discharge plans and connecting them to community services and providers. Because this is an emerging care model, the findings will help provide the evidence needed to make a case for implementing patient navigators for older adults with complex care needs in a hospital setting. This research informs decision makers on the role of a patient navigator who is a community social worker for older adults with complex care needs and their caregivers in transitioning from a hospital setting to their home. To our knowledge, this is the first Canadian study to describe a PN program for older adults with complex care needs in a hospital setting where the patients are followed up for up to 90 days. This study contributes to the research on the patient navigator role in a hospital setting; however, further research is recommended to evaluate the impact of PN interventions on outcomes.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/S0714980824000321.
Acknowledgements
The authors would like to thank Navin Goocool and Karen Chan at Sunnybrook Health Sciences Centre Decision Support, Coding, Data Quality and Reporting Services for their assistance with the extraction of hospital administrative data. The authors would like to also acknowledge Rachel Russell, Research Coordinator, at St. John’s Rehab Research Program and Emma Elliot, Director of Community Services, at SPRINT Senior Care for their support.
Financial support
This research was funded by The SLAIGHT Family Foundation. The funder had no role in the design of the study design, data collection and analysis, or interpretation of data; or in the writing of the manuscript, or in the decision to publish the results.
Competing interest
The authors Amanda Knoepfli, Tracey DasGupta, and Naomi Ziegler manage the Patient Navigation Program. Grace Liu, Kristina M. Kokorelias, Sara J.T. Guilcher and Sander L. Hitzig have no conflicts of interest to declare.
Ethical approval
This study was approved by the Sunnybrook Health Sciences Research Ethics Board [#1598] and SPRINT Senior Care.
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