Navigating Patients to More Cost-Effective Settings at Denver Health
Patient navigation programs help patients circumvent the many barriers—financial, logistic, and social—that make it difficult to use the healthcare system. The main intent is to improve access to needed services. Proponents also believe navigation programs can produce a positive—or at least a neutral—cost savings for hospitals and health systems that hook patients up with Medicaid and other payment options and direct uninsured patients to the most cost-effective settings.
Denver Health, the safety-net health system
in the Mile-High City, originally received grant
funding to provide patient navigation for
underserved men in its service area in 2002. By
the time the grant ended, the health system was
convinced the program was worth paying for with
internal funds.
“We discovered that the patient navigators
helped us avoid almost $300,000 worth of costs a
year, because they help the men use our system
more appropriately,” says Elizabeth Whitley,
PhD, RN, director of Community Voices, a group
of community-based initiatives that increase
access to care for the underserved. “Not only
did the navigation help the patient, but it also
helps our system.”
The Pilot Program
Denver Health’s initial navigation program targets men who are
uninsured or underinsured, men of color (because they access
health care less than others), and homeless men. Two patient
navigators go out in the community (for example, to prisons,
homeless shelters, and community-based organizations) to connect
with patients who need help receiving healthcare services.
Whitley’s ROI analysis of the program during its initial grant
period found that patient navigation decreased patient visits to
the system’s emergency department, urgent care centers and detox
facility, while it increased patient use of less expensive
primary care and specialty care.
Adding More Navigators
Since then, Denver Health has pursued many
opportunities to add patient navigation
services.
“Our whole goal is to decrease barriers. And
financial barriers are probably the biggest and
the most common barriers that our patients
face,” says Whitley. “We’ve really invested in
patient navigation in a big way right now.”
The health system employs 15 navigators in six
different programs for approximately $521,000,
plus benefits. Denver Health’s operations budget
covers the two navigators for underserved men—at
about $75,000, plus benefits—while the other
positions are grant-funded.
Costs associated with a patient navigation
program include training of the navigators,
office space, cell phones, computers, and
supplies. More important, though, are the costs
associated with reducing barriers to care, such
as the cost of covering bus tokens, cab
vouchers, and medical and prescription copayment
assistance. The Denver Health Foundation has a
patient assistance fund that provides some
funding for these needs.
In addition to the navigators for underserved
men, Denver Health employs a number of other
navigators to help achieve various other goals.
Increase screening rates. One patient
navigator works with a mobile mammography unit.
Before navigators were available, the unit had a
no-show rate of nearly 50 percent. The navigator
helps women keep appointments by providing
reminders, identifying and solving
transportation problems, and rescheduling when
necessary. If the mammogram is abnormal, the
navigator helps the patient make the necessary
follow-up appointments right away.
In addition, two navigators, funded through a
state program, help uninsured patients get free
colonoscopies. The patients are identified
through provider referral and Denver Health’s
electronic medical record (EMR), which shows
whether they are due for a colorectal screening.
Plus, three navigators, also funded by a state
grant, provide cardiovascular disease screening
in 20 barbershops across the Denver area.
Help cancer patients navigate the system.
Four navigators are associated with a nine-site
Patient Navigation Research Program, funded by
the National Cancer Institute and the National
Institutes of Health, to study the effect of
navigation on breast, colorectal, or prostate
cancer patients. Patients are invited to
participate in the study if the EMR flags a
cancer diagnosis or an abnormal lab or imaging
finding.
Improve chronic disease management. Three
navigators, funded by a state grant, work with
patients who have diabetes and hypertension.
Individuals are identified to participate in the
program if a Denver Health disease registry
shows their chronic conditions to be poorly
controlled. A navigator invites these patients
to come into a clinic for primary care, lab
work, and screenings, with the goal of improving
their chronic condition and overall health
status.
An Emphasis on Financial Assistance
When a navigator first connects with a
patient, the first goal is to enroll the patient
in publicly-funded health insurance or other
financial assistance programs. For example, men
in Colorado are not eligible for Medicaid unless
they are responsible for dependent children or
are disabled. So the navigators help them apply
for a sliding-fee discount program.
Similarly, the navigator helps arrange financial
assistance—available through a Denver Health
foundation—for copayments and medications. The
navigators also provide bus tokens and taxi
vouchers to help their clients get to
appointments, or alternatively, the navigators
arrange for transportation by Denver Health’s
car and driver. “And the navigators work with
patients on any language and literacy issues,
and even just how to get around the Denver
Health system, which is quite large and
convoluted,” says Whitley.
In addition, the navigators escort patients who
have mental health problems, language barriers,
or are nervous about getting lost on the
hospital campus and, if necessary, actually sit
in on appointments with the patients.
“Physicians like it a lot because, if there is a
misunderstanding (in patient-physician
communication), the navigator often identifies
it and clears it up,” she says.
More ROI Data Needed
Desired outcomes vary among the navigation
programs at Denver Health. For example, the goal
of Denver Health’s navigation for underserved
men is to help the patients access services and
use the system more effectively. But the goal of
the cancer patient navigation program is to
decrease the amount of time it takes for a
patient to move from an abnormal finding to a
diagnosis or from a diagnosis into treatment.
Whitley says patient navigation needs more
research to understand its efficacy as well as
cost effectiveness. She believes it ranks high
in patient satisfaction. “The patients certainly
like it because they feel better connected to
the system. There’s a person that they can
call—they have a face, a name, and a phone
number of someone who cares about them.”
Hospitals that establish patient navigation
programs should set up an evaluation process
before the service begins, advises Whitley. That
allows an assessment of the impact of patient
navigation not only on patient outcomes, but on
hospital finances as well.
Many patient navigation programs start with
grant funding, which will eventually end. “You
need to identify the desired outcomes to measure
up front because, if the grant is over and you
don’t have measureable results to show for it,
then those navigators most likely are going to
go away,” says Whitley.
This case study is pulled from a series of
articles on patient navigation that ran in
HFMA’s Patient Friendly Billing newsletter.
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