Abstract
Background: Northern Health, along with health systems worldwide, is experiencing increasing demand due to population growth, aging and increasing rates of multimorbid chronic disease alongside complex social conditions. NH catchment area includes culturally and linguistically diverse residents, with lower levels of income, educational achievement, health literacy and employment than the Victorian average. As health services grow, they become increasingly difficult for patients to navigate. The need for proactive community-based care, and the use of non-clinician local supports is evident. Internationally, peer health navigators have been shown to improve patient use of health services and reduce acute hospital needs.
Approach: The Northern Patient Watch (NPW) programme is based on a model where local community peer health navigators (“telenavigators”) provide weekly support and proactive monitoring over months to years, developing rapport and trust. Patients are selected using algorithms designed to identify patients at high risk for a future hospital admission within 12 months. Signs of health decline or concerns raised by patients or navigators are escalated as required to “health coaches” with a range of clinical backgrounds. Person-centred goals and actions facilitate self-management and access to the right care at the right time. Resources, ideas and strategies are shared between telenavigators and health coaches with different experience, skills and health disciplines within the team, alongside regular input from a medical lead via case conferences and consultation as required. This study aimed to assess the impact of NPW on hospital admissions, bed days, emergency department presentations, and outpatient non-attendance.
A propensity score matching design was used to compare NPW participants with controls over 3-, 6-, and 12-month follow-up periods. Acute hospital needs and bed days were the primary outcomes, with secondary outcomes including outpatient appointment non-attendance rates. Data were analysed using statistical methods appropriate for normally and non-normally distributed variables, with adjustments made for potential confounders.
Results: NPW participants had reductions in hospital bed days across all time points compared to matched controls. By 12 months the median total bed days was 2.00 (IQR 0.00, 8.00) for NPW participants and 4.00 (IQR 1.00, 14.00) for matched controls, p 0.008. There were trends towards lower admission and emergency presentations rates, however these differences were not statistically significant. Outpatient appointment non-attendance rates were significantly lower in the NPW group at 12 months (44.8%) compared with matched controls (55.6%), p 0.01, indicating improved engagement with healthcare services.
Implications: The NPW programme was associated with reduced hospital bed days and improved outpatient appointment attendance, but no significant difference in hospital presentation or admission rates. These findings suggest that local community lay health navigator programmes supported by clinicians, may be an effective strategy to engage with and support patients in a person-centred manner while reducing overall acute hospital needs. The program may be improving self-management and early detection of deterioration, resulting in proactive care-seeking and management, reducing hospital-based length of stay. Expanding the scope of future studies to include patient lived experiences, and longer term follow up would provide more comprehensive understanding of the programme’s impact and sustainability.