Abstract
Background: For many older adult hospital patients with complex health and social needs, hospital to home transitions can be a stressful time for older adults and their caregivers. There are several factors that make care transitions challenging, including a siloed approach to care. A consequence of this siloed approach, which hampers the ability of providers to optimize service delivery, is that older adults with complex care needs and their family caregivers experience many barriers once they leave the hospital, such as challenges with accessing appropriate health and social care, a lack of knowledge and information about their care plans and high rates of caregiver burnout. Patient navigation has emerged as one solution to integrating care to address patient, caregiver and healthcare providers (HCPs) needs as it relates to hospital to home transitions.
Methods: The Senior Care Navigation Pilot is a hospital-and-community-based model of care that includes a designated patient navigator role to help identify care needs, support discharge planning and coordinate and integrate care regardless of institutional and geographical boundaries for up to 90 days post-hospital discharge. Our study used a qualitative descriptive methodology and semi-structured interviews with HCPs (n=48) working in health and social care sectors across Toronto (Ontario), family caregivers (n=6) and older adults (n=8) enrolled in the Senior Care Navigation Pilot to explore their experiences with patient navigation. Data were analyzed thematically.
Results: Preliminary analysis from an initial set of interviews with 61 participants revealed four themes: 1) Role Clarity; 2) Meeting Evolving Needs; 3) Helping Me Stay Home Safely; and 4) Characteristics of the Patient Navigator (PN). Participants described an inconsistent understanding of the role of PNs, which led to uncertainty regarding their expectations of what the PN could accomplish or add to the care process. Nonetheless, participants described that PNs were able to meet needs across the illness and care continuum by respecting patient choices, improving the continuity of care and finding resources and services to meet care needs as they evolved. All participants believed that the presence of PNs help to sustain care in the community by being a consistent source of support and making timely, appropriate referrals. Lastly, all participants described the navigators in terms of their personality and credentials, particularly noting their ability to be nimble and kind.
Discussion: Our findings highlight that there was perceived value in PNs but further work is required to better clarify their role and how to better integrate them into the clinical team. PN models of care, such as the Senior Care Navigation Pilot, can help accelerate integrated care for older adults and provide a better work experience for HCPs by enabling an extra support (i.e., navigator) to their care teams.
Conclusion: Our preliminary data evaluating a pilot patient navigator program has shown promising benefits, including improved transitions in case, an increase in access to appropriate healthcare and community-based services and greater support to care teams; all of which have the potential benefit of enhancing the effectiveness of care systems and improving patient and caregiver well-being.