Patient Care Navigators Help Make Health Care Journey a Success

Calisa Williams provides navigator services through the Medical Home Network.

Imagine traveling abroad by yourself, but you’re not fully equipped with the information you need to make the trip successful. It would feel pretty overwhelming and confusing, right? This is what the health care system can feel like for patients who are unfamiliar with how it works.

Patient care navigators answer that need. These non-licensed people come from the communities we serve and help connect patients to the appropriate resources and places of care as they wind their way through the health care system.

“Health care is often referred to as a journey,” says Michael Hanak, MD, associate chief medical officer for population health. “If you think about all the things that have to go right to travel to a new place, knowing when the plane leaves is essential. But what if you needed help planning, packing, getting to the airport, understanding how to check in and find your gate, and after landing — ​making your way to your final destination?

“Our navigators make complicated things simple and dedicate themselves to ensuring all patients are successful in their journey,” adds Hanak, who also is an associate professor in the Rush Department of Family Medicine​​.

Patient care navigators may schedule appointments, arrange transportation, perform health risk assessments for frequent hospital and emergency room use, and connect patients to care management or navigate insurance and in-network providers. They are often the first point of contact for many patients and can serve as a significant support for patients who aren’t otherwise familiar with the health care system.

The role of patient care navigators also varies according to what areas of care they support. The following are just six types you may find at Rush University Medical Center and a broad overview of what support each role provides:

  • Ambulatory Quality Team Navigators: These navigators identify Rush University Medical Group (RUMG) patients with outstanding care gaps, such as hypertension, diabetes, colorectal screening and breast cancer screening. They also schedule the necessary appointments so patients can get much needed preventive care measures met, identify patients who qualify for an annual wellness visit and schedule the necessary pre-visit and provider visits to get Medicare patients access to care.
  • Medical Home Network CountyCare/Medicaid Accountable Care Organization (ACO) Navigators: These navigators support nurse and social work care managers with managing the care of at-risk CountyCare/Medicaid Accountable Care Organization ​(ACO) patients, complete health risk assessments, coordinate transportation and assist patients with renewing insurance, scheduling appointments and connecting patients to community resources.
  • Medical Home Network Post-Acute Care Navigators: These navigators provide transitions of care for all CountyCare patients who belong to the Medicaid ACO (known as MHN ACO​), and who are admitted to a skilled nursing facility, long-term acute care or rehabilitation. These individuals visit all admitted Medicaid ACO patients in the facility and connect the facility providers with providers from the patient’s medical home to facilitate a smooth discharge and transition process once the patient is discharged to their home. This includes ensuring the primary care physician understands the facility’s discharge instructions and has the latest medication list, and that the providers and outpatient care managers are informed of the care plan.
  • Oncology Care Model Navigators: These navigators support the nurse and social work care managers with care managing at-risk Medicare cancer patients who are on chemotherapy. These individuals assist with helping patients sign up for Medicare (Senior Health Insurance Program counseling), follow up on recently discharged patients, introduce them to the care management program, address social determinants of health and play a crucial role in the Rush University ​Cancer Center ​advanced directives initiative.
  • Rush@Home Navigators: These navigators receive referrals for home-bound RUMG patients who meet criteria to enroll in the program, identify patients who may qualify, schedule appointments according to their proximity to one another, follow up on home health orders, are the first points of contact for all patients and coordinate with Rush ​University Internists​ and Rush Senior Care to align clinic and Rush@Home schedules.
  • Transitional Care Program Navigators: These navigators support the patient’s discharge plan by assisting the patient in scheduling post-discharge hospital follow-up appointments for all patients admitted to designated units at Rush, identify in-network providers for patients both in and out of network with Rush, navigate uninsured patients to accessible and affordable care, connect patients to the appropriate care management team and follow up on social determinants of health needs. They also follow up on Adverse Childhood Experiences (ACE) screenings that indicate ACE events occurred in pregnant women and new moms ​with positive adverse childhood events screens, and they connect new mothers to appropriate home visiting agencies and community resources.

It’s clear that without patient care navigators in place, the health care journey for many would be incredibly difficult. It’s easy to overlook these small details, yet the results of their efforts can be life-changing. They take care of so many details behind the scenes it almost looks effortless. 

“The patient care navigators are essential to every population health initiative we have at Rush,” adds ​Vidya Chakravarthy, MS-HSM, director, Population Health. “Their dedication to our patients and the communities we serve is inspiring and evident in each of their interactions with patients and staff. Our navigators form the bridge between the hospital and our communities and connect us closer to the patients we serve. Thank you for everything you do.”​ ​

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