Health Navigator
Health Navigator - Changing the System to Meet the Needs of the Patient
HIP's Health Navigator Program provides hands-on help to low-income, uninsured, recently hospitalized patients. This position is filled by a bilingual, bicultural HIP staff member who is uniquely skilled at coordinating the health and social service needs of her clients, including enrollment in Medi-Cal or County benefits, assistance with discharge medications, linking patients to a regular source of primary care, and shelter or other services. The goal of the Health Navigator program is to improve the health outcomes of those served, reduce preventable hospital readmissions, and link uninsured individuals to critically needed primary care services.
Background
In April 2010, HIP launched a Health Navigator program in collaboration with Dominican Hospital, Watsonville Hospital, the Safety Net Clinic Coalition and the Santa Cruz County Homeless Person's Health Project. The program is beginning with one year pilot employing a Health Navigator to assist uninsured hospital patients to link to primary care clinic and other community-based services following an inpatient hospital stay.
The Health Navigator pilot is being designed and implemented using the IHI Triple Aim framework starting with the patient experience. Outcome metrics including 30-day rehospitalizations, emergency room visits, hospital days, and access to a primary care and other community services are being used as small tests of change to continuously improve the Health Navigator pilot.
One of the most innovative features of the program is a patient survey which the Health Navigator discusses with the patient at 30 and 90 days following hospital discharge. A final report on the outcomes of the health navigator pilot and lessons learned will be available in Spring 2011.
Triple Aim Site Team
The Triple Aim Site Team meets monthly to guide the implementation of the Health Navigator pilot program, inviting other community partners to attend as Fix-It issues arise. Team members also participate in IHI Triple Aim conferences and webinars and serve as the on-site mentor for the Health Navigator in their respective facilities.
- Janice Sanning RN, Director Case Management, Dominican Hospital
- Rondi Hansen RN, Director of Case Management, Watsonville Hospital
- Christine Sippl MPH, Senior Health Services Manager, Homeless Persons Health Project
- Barbara Palla MD, Consulting Physician, HIP/Safety Net Clinic Coalition
- Eleanor Littman RN, Executive Director, HIP