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Health Navigator

2012-2013 Health Navigator Program

Launched in October 2012, the second iteration of the Health Navigator Program again represents a community-wide partnership between HIP, the County Health Services Agency, County and community clinics, and local hospitals, but now employs a multidisciplinary and coordinated care team. This diverse team is guided by a HIP-based Consulting Nurse, Consulting Physician, and Program Coordinator who work with a County RN Nurse Navigator and County Social Worker, as well as embedded team members at 3 participating clinic organizations.

The team interacts with clients, many of whom have been recently discharged from the hospital, through home and community visits, and coordinates closely with primary care clinics to ensure that clients receive the warm handoff they need to achieve better health outcomes. This includes assisting post-discharge with access to medical, social, and behavioral health services, as well as benefits information and transportation to and from appointments, ultimately helping clients overcome the barriers that prevent utilization of primary care.

The goal of the program is to help higher-risk, low-income newly insured and uninsured clients integrate into their health home in order to decreased avoidable hospital re-admissions, enhance the patient experience of care, and decrease overall costs to the health care system. The program focuses primarily on individuals enrolled in MediCruz Advantage, the County's Low-Income Health Program, but also sees complex uninsured or underinsured adults. From October 2012 through December 2013, 140 individuals were enrolled in the program.

The program is funded by grants from The California Wellness Foundation and the Health Home Innovation Fund (a grantmaking program of the Center for Care Innovations), and by in-kind support from the Santa Cruz County Health Services Agency. The Health Improvement Partnership serves as the neutral coordinator and administrator.

Our client feedback indicates a high level of satisfaction with the program, and our readmission rate remains very low, indicating that the program is successful at changing the utilization patterns of adults who are new to or are unfamiliar with the health care system. With the Health Home Innovation Fund and County staff support for the Health Navigator Program ending in December 2013, the Health Improvement Partnership is exploring strategies for sustaining and expanding the program in 2014 and beyond.

2010-2011 Health Navigator Pilot

Santa Cruz County health care leaders recognized the need for uninsured adults to be successfully navigated through the health care system and linked with a medical home following their stay in the hospital, both to improve health outcomes and reduce cost. Navigating follow-up care after discharge can be very confusing, and patients who are not able to effectively navigate their post-discharge care (make and keep follow-up appointments with a primary care physician, take and fill prescriptions for medications, etc.) are more likely to be re-admitted.

In 2010-2011, the Health Improvement Partnership of Santa Cruz County (HIP) received a Federal earmark to investigate the value of a hospital-based community educator to assist uninsured, low-income adults with the hospital to outpatient transition, including linkage to a medical home, community services, and health coverage, if possible. The Health Navigator Pilot, which represented a partnership between HIP, Dominican Hospital, Watsonville Hospital, the Safety Net Clinic Coalition and the Santa Cruz County Homeless Person's Health Project (HPHP), followed the IHI Triple Aim goals of improving the patient experience of care, reducing the overall cost of care, and improving population health. Specifically, the Pilot focused on:

  • Reducing preventable hospital re-admissions by assisting with the insurance eligibility and enrollment process in order to help clients negotiate access to complex health service systems and reduce the risk of future hospitalizations following discharge. (reduce cost)
  • Linking uninsured individuals to critically needed primary care services by scheduling post-acute follow-up appointments with primary care providers and ensuring a solid connection to a primary care home. (improve the experience of care and promote better health)


The Health Navigator was a bilingual/bicultural community educator who provided hands-on help to 192 patients, successfully reducing 30-day re-hospitalizations, increasing 30-day follow-up appointments and improving patient satisfaction of care. Out of the Pilot came several lessons learned, including the need for a navigation team to deal with the complex medical, social, and behavioral health needs of the patients served. These lessons helped inform the design of the 2012 Health Navigator Pilot Program.

2012 Health Navigator Pilot Program

Beginning July 2012, the second Health Navigator Pilot Program again represents a community-wide partnership between HIP, the County Health Services Agency, County and community clinics, and local hospitals, but now employs a multidisciplinary and coordinated care team. This diverse team is guided by a HIP-based RN Program Coordinator who works with a County RN Nurse Navigator and Mental Health Specialist, as well as embedded team members at four participating clinics, to help high-risk clients better access primary care, behavioral health, and social services. The program focuses primarily on individuals enrolled in MediCruz Advantage, the County's Low-Income Health Program, but also sees a small number of complex uninsured or underinsured clients.

This program is funded in part by a grant from The California Wellness Foundation, the Health Home Innovation Fund (a grantmaking program of the Community Clinics Initiative), and by in-kind support from the Santa Cruz County Health Services Agency.

These lessons helped inform the design of the 2012-2013 Health Navigator Program.