The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: patient engagement

Patient Navigators and Their Value to Hospital Care

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Since the 1990s, patient navigators have helped guide and support patients through a diagnosis, or suspected diagnosis, to address any barriers patients may encounter within the health care system. This ensures patients are informed and receiving timely treatment. Patient navigation programs have traditionally been attributed to oncology; however, these programs have demonstrated value across different lines of care, especially in geriatric care where care is costly and multifaceted. 1

Patients can benefit immensely from navigator programs. Navigators ultimately ensure that patient needs and questions are addressed, that they are adhering to their medication plans, and that they are well-informed of their diagnosis and treatment status. By working one-on-one with patients, navigators help address broader health disparities, such as language barriers, that may not be feasible to clinicians due to resource and/or time constraints. This helps support patients during critical, and often complex, times in their health by providing them with the necessary tools and guidance needed in treatment and healing. 2

Patient navigator programs benefit not only patients, but also help improve cost outcomes. A study by Rocque, Gabrielle B., Pisu, M. et al. examines cost and resource use related to cancer among older adults (Medicare beneficiaries 65 years or older) receiving care at The University of Alabama at Birmingham (UAB) Health System Cancer Community Network (CCN). In the study, the Patient Care Connect Program (PCCP) was implemented, which aimed to optimize costs through the integration of lay navigators within the CCN. Using claims data, navigated patients and non-navigated patients were observed from 2012-2015 for any changes in total Medicare costs and resource use.  Costs related to hospitals, outpatient, and physician visits were examined. Those in the navigated group, comprised of a single navigator and 152 patients, had declining costs for a total of over $475,000 reduction, annually. The reduction takes into account an average salary and benefit investment estimated at $48,448 for the navigator. ED visits and hospitalizations of those in the navigated groups decreased by 6% and 10.6%, respectively, per quarter compared to those in the comparison group (non-navigated). The study helps quantify the value of patient navigators in a health care setting, including through the prevention of ED and hospitalizations that may also improve patient experience. This study can be found here: 1

Incorporating a patient navigation program into a health system can be beneficial to different parties involved in patient care. The benefit gained from patient navigation programs supports value-based care models that are being implemented across the nation. These programs ensure that patient needs impacting clinical outcomes are being addressed and support hospital financial viability. Although patient navigation is not brand new, programs are now surfacing as they support the goals of the movement towards value-based care.



1Rocque GB, Pisu M, Jackson BE, Kvale EA, Demark-Wahnefried W, Martin MY, Meneses K, Li Y, Taylor RA, Acemgil A, Williams CP, Lisovicz N, Fouad M, Kenzik KM, Partridge EE, for the Patient Care Connect Group. Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer. JAMA Oncol. 2017;3(6):817-825. doi:10.1001/jamaoncol.2016.6307

2 Paskett ED, Krok-Schoen JL, Gray DM. Patient Navigation—An Effective Strategy to Reduce Health Care Costs and Improve Health Outcomes. JAMA Oncol. 2017;3(6):825-826. doi:10.1001/jamaoncol.2016.6107

Michigan Innovators: Improving Patient Discharge at St. Mary Mercy Livonia

Maya Peters is a research associate with MVC.

Members of the Care Transitions team at St. Mary Mercy Livonia recently shared with MVC an innovative effort to improve the discharge process at their hospital, which resulted in increases in the HCAHP scores for both Patient Satisfaction and Transitions of Care. I had the privilege of speaking with Catherine Ponder, RN, BSN, and Sue Klotz, MS, BSN, RN-BC, both of whom were integral in the development and implementation of a concise, organized system to manage the personalized information each patient receives throughout their hospital stay.  

An unorganized discharge process leads not only to confusion, but can contribute to future readmissions due to medical discrepancies, unscheduled follow-up appointments and a lack of education on disease symptoms. Catherine and Sue’s team realized many patients struggle to keep all of the information received at the hospital straight after being discharged, and often feel overwhelmed once they’re back at home. 

To help address the disjointed nature of the acute to post-acute transition, the care transitions team, along with input from frontline RNs and the Patient Family Advisory Council, created a three pocket folder that each patient receives upon admission to the hospital. This folder follows each patient throughout their hospital stay and extends into the home. The contents of the folder include: name and number of the patient’s primary doctor and follow-up appointment; discharge information, including symptoms and the patient’s health problems; medications, prescriptions, and side-effects; education materials, advanced directives, goals of care; and finally, questions the patient has for their doctor. The folder is introduced to the patient upon admission.  A nurse helps patients to fill out the “Questions for my doctor” section, and other medical professionals visiting the patient may add relevant materials to the folder as needed.  The day following discharge, each patient receives a follow-up phone call.

Initially conceived in 2012, the folder has undergone a number of iterations and revisions. The Marketing team helped make the folder as usable as possible for seniors by increasing the font size, adding icons and using concise language.  According to Catherine and Sue, the key to making the discharge folder initiative and implementation successful was the involvement, assistance and engagement of the nurse practice council who were actively involved and provide ongoing feedback.

Since the roll-out of the new discharge process in summer 2015, Catherine and Sue have seen positive results in supporting patient engagement.  More importantly, one of the most rewarding aspects of the program is seeing patients’ confidence increase.  The folder allows patients to feel more capable of managing their health and discussing their needs with medical professionals.

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