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 (link to exhibit).

 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 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 patients 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.

Lay Versus Clinical Navigators

Denver Health experimented with using nurses and social workers as patient navigators, but found the approach to be quite expensive-and staff feared this approach might pull nurses away from direct care roles where they are badly needed. "We have tried a number of models and believe that lay navigators are a less expensive way to help people decrease their barriers," says Whitley.

At Denver Health, lay navigators are required to have some college courses or a professional degree, if they were educated in another country. Alternatively, they can complete a 17 credit-hour certification program for community health workers offered through the local community college.

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.


Interviewed for this case study: Elizabeth Whitley, PhD, RN, director of Community Voices at Denver Health (Elizabeth.Whitley@dhha.org).

Publication Date: Friday, May 01, 2009