Abstract
Background:
Health navigators are healthcare professionals who specialize in care coordination, case management, navigating transitions, and reducing barriers to care. There is limited literature on the impact of health navigators on community-based palliative care for people experiencing homelessness.
Aim:
We devised key performance indicators in nine categories with the aim to quantify the impact of a health navigator on the delivery of palliative care to patients experiencing homelessness.
Design:
Data were collected prospectively for all patient encounters involving a health navigator from July 2020 to 2021 and reviewed to determine the distribution of the health navigator’s role and the ways in which patient care was impacted.
Setting and participants:
This study was conducted in Toronto, Ontario with the Palliative Education and Care for the Homeless (PEACH) Program. At any one time, the PEACH health navigator served a total of 50 patients.
Results:
We identified five key areas of the health navigator role including (1) facilitating access (2) coordinating care (3) addressing social determinants of health (4) advocating for patients, and (5) counselling patients and loved ones. The health navigator role was split evenly between activities pertaining to palliative care for structurally vulnerable populations and community-based palliative care for the general population. To achieve high impact outcomes, a considerable investment of time and energy was required of the health navigator, speaking to the importance of adequate and sustainable funding.
Conclusions:
These findings underscore the potential for health navigators to add value to community-based palliative care teams, especially those caring for structurally vulnerable populations.
Keywords: Palliative care, community services, social impact, health impact assessment, outcome measures, homelessness, health equity, social workers
What is already known about the topic?
Health navigators positively impact the patient experience of palliative care through coordination of care, case management, navigating transitions, and reducing barriers to care.
What this paper adds?
A professional health navigator can improve access to care and help meet the social needs of palliative care patients experiencing homelessness, and the impact of this can be measured.
Implications for practice, theory or policy
Community-based palliative care teams may consider incorporating a professional health navigator into their model to improve access to care, and doing so may lead to wider societal impacts to support structurally vulnerable populations.
Background
Amongst individuals experiencing homelessness, specific groups are overrepresented, including Indigenous and racialized individuals, people who first experienced homelessness in their youth, people who have experienced foster care, and individuals who identify as 2SLGBTQ+. 1 Research has clearly shown that people experiencing homelessness are at increased risk for illness and mortality, and there are significant systemic barriers to them receiving good palliative care at the end of life.2–5
A health navigator is a healthcare professional or peer who specializes in coordination of care, case management, navigating healthcare transitions, and reducing barriers to care.6–14 Multiple studies have demonstrated the positive impact of social workers on palliative care teams, including their capacity to improve quality of care, facilitate discussions about advance care planning, educate patients and families, help patients achieve prognostic alignment, screen for bereavement needs, and lead team discussions.15–21 Moreover, there is research demonstrating that health navigators can improve the health care of underserved patients. 22 However, there is little research to date on the potential for social workers as health navigators to facilitate equitable access to palliative care amongst structurally vulnerable populations, and to our knowledge there are no studies demonstrating the impact of a professional health navigator in community-based palliative care for individuals experiencing homelessness.
The Palliative Education and Care for the Homeless (PEACH) program is a community-based palliative care program in Toronto, ON developed in response to a need for the delivery of equity-oriented palliative care to individuals experiencing homelessness. 23 At the beginning of the COVID-19 pandemic, PEACH received funding to establish a health navigator role with the aim of providing social care through addressing the housing, income, food security and access to health care needs of this patient population. An individual with a Master of Social Work was hired for this role given their specialized skills in systems navigation, interdisciplinary collaboration, and evaluating and meeting the social needs of their clients.
In this study, we sought to characterize the activities of health navigator with a Master of Social Work delivering palliative care to individuals experiencing homelessness, and evaluate the impact of a health navigator on the delivery of community-based palliative care to people experiencing homelessness in Toronto, ON. We hypothesized that over a 1-year period the addition of a health navigator to the PEACH program would facilitate access to palliative care and social services as well as help overcome structural barriers to health and well-being for people experiencing homelessness while receiving palliative care.
Methods
Design of service evaluation
For the purposes of this study, an original service evaluation tool was designed collaboratively by the authors to capture the roles and responsibilities of the PEACH health navigator. Unique key performance indicators (KPIs) were devised for the purposes of evaluation and categorized into one of two domains, including KPIs applicable to (1) palliative care for people experiencing homelessness and (2) general community- and home-based palliative care, or “mainstream” palliative care. KPIs in Domain One were derived from the PEACH health navigator job description, while those in Domain Two were derived from current literature pertaining to the role of a health navigator in general palliative care settings, including both community- and home-based settings.15–21,24 A total of nine KPI categories and 51 individual KPIs were included (Table 1).
Table 1.
Key performance indicators (KPIs) to measure the impact of a health navigator in community-based palliative care for people experiencing homelessness.
| Key performance indicators by domain and category | |||
|---|---|---|---|
| Domain One: People experiencing homelessness or living in vulnerable housing | Category One: Housing | Domain Two: General community-based palliative care | Category Five: Accompaniment to medical appointments |
| KPI 1.1 Referral to shelter-hotel program | KPI 5.1 Attended health appointment with client | ||
| KPI 1.2 Housing application discussion | KPI 5.2 Accompanied to PCU admission | ||
| KPI 1.3 Housing application submitted | KPI 5.3 Facilitated virtual care appointment | ||
| KPI 1.4 Housing application advocacy | Category Six: Access to interdisciplinary care | ||
| KPI 1.5 Accompany to view housing offer | KPI 6.1 Connected to dentist or optometrist | ||
| KPI 1.6 Housing secured | KPI 6.2 Connected to occupational or physiotherapy | ||
| KPI 1.7 Housing maintained >12 months | KPI 6.3 Connected to addictions support worker or case manager | ||
| KPI 1.8 Eviction prevented | KPI 6.4 Aided in referral to specialist | ||
| KPI 1.9 Advocacy to maintain housing | KPI 6.5 Coordinated with specialist | ||
| KPI 1.10 Arrange extreme clean or pest control treatment | Category Seven: Counselling and psychosocial support | ||
| KPI 1.11 Arrange maintenance visit or place work order request | KPI 7.1 Counselling provided | ||
| Category Two: Income | KPI 7.2 Referral made to mental health provider | ||
| KPI 2.1 Application for ODSP/CPP-D | Category Eight: Capacity building or partnership development | ||
| KPI 2.2 Secured ODSP/CPP-D | KPI 8.1 Conducted presentation about PEACH | ||
| KPI 2.3 Application for ODSP Transportation Coverage | KPI 8.2 Involved in media respresentation of PEACH | ||
| KPI 2.4 Application for ODSP Medical Necessities Benefit | KPI 8.3 Quantifiably extended reach | ||
| KPI 2.5 Application for shelter allowance | KPI 8.4 Facilitated grief circle for community partners | ||
| KPI 2.6 Application for Housing Stabilization Fund | Category Nine: Patient advocacy and health outcomes | ||
| KPI 2.7 Assist with client finances | KPI 9.1 Optimized care by attending case conference meeting | ||
| Category Three: Food (In)Security | KPI 9.2 Prevented adverse health event through surveillance | ||
| KPI 3.1 Connected to Food Bank | KPI 9.3 Affected positive change in care through surveillance | ||
| KPI 3.2 Connected to Meals on Wheels | KPI 9.4 Facilitated symptom management conversation | ||
| KPI 3.3 Connected to grocery gift card program | KPI 9.5 Documented advance care planning discussion | ||
| KPI 3.4 Advocacy regarding food security at case conference | |||
| Category Four: Referrals and coordination | |||
| KPI 4.1 Hospice Toronto visitor volunteer referral | |||
| KPI 4.2 Referral made to Good Wishes Project | |||
| KPI 4.3 Wheel Trans application | |||
| KPI 4.4 Connected client with PAID ID clinic | |||
| KPI 4.5 Facilitated health card renewal | |||
| KPI 4.6 Coordinating safety planning | |||
| KPI 4.7 Coordinating medication pick up and delivery | |||
| KPI 4.8 Led discussion with family | |||
| KPI 4.9 Coordinated taxi or wheel trans booking | |||
| KPI 4.10 Coordinated other (i.e. LHIN services) | |||
PCU: palliative care unit; ODSP: Ontario disability service pension; CPP-D: Canadian pension plan – Disability benefit.
Setting and population
This study was conducted in Toronto, ON, with study approval granted by the Inner City Health Associates research oversight committee. The PEACH health navigator position was occupied by one individual throughout the duration of the study. At any one time, the health navigator served a total of 50 patients experiencing homelessness. While there are many definitions of homelessness, PEACH considers an individual to be experiencing homelessness if they are sleeping outside, couch-surfing, living in shelter, or vulnerably housed in temporary or permanent housing.
Data collection
KPIs were tracked prospectively by the PEACH health navigator between July 2020 and July 2021. Each time the health navigator carried out an activity or achieved an outcome corresponding to a KPI, it was logged in an anonymized excel spreadsheet for tabulation. These encounters were also documented in the patients’ electronic medical record.
Data analysis
All data points were tabulated to calculate the total number of times each individual KPI was achieved as well as the total number of occurrences logged per KPI category. KPIs were further categorized by rate of completion, including those completed at low frequency (0–1 times), moderate frequency (2–9 times) and high frequency (10+ times) during the study period.
Collated data were then interpreted to understand the distribution of the health navigator’s role and examine its impact on the delivery of palliative care to individuals experiencing homelessness. The health navigator role was further characterized using three distinct methods of analysis, which are detailed in the supplementary material (Supplemental File 1). KPIs are considered a direct reflection of the health navigator’s activities, and are therefore referred to as “activities” in both the results and discussion sections.
Findings
Between July 2020 and July 2021, the PEACH health navigator logged a total of 407 activities reflecting the KPIs devised to capture their role. In the domain of providing palliative care to people experiencing homelessness, the health navigator completed a total of 207 activities, and in the category of general community-based palliative care, or “mainstream” palliative care, a total of 200. The health navigator’s role encompassed all overarching categories to varying degrees, including referrals and coordination (77), accompaniment to medical appointments (72), housing (60), patient advocacy and health outcomes (59), income (51), access to interdisciplinary care (35), counselling and psychosocial support (25), food (in)security (19), and capacity building and partnership development (9) (Table 2).
Table 2.
Key performance indicator (KPI) by total number of events per category and KPIs per frequency category.
| KPI Category | Total Number of Events | Number of KPIs per Frequency Category | |||
|---|---|---|---|---|---|
| High a | Moderate b | Low c | |||
| Domain One: People experiencing homelessness | Housing | 60 | 1 | 8 | 2 |
| Income | 51 | 2 | 6 | 1 | |
| Food (In)security | 19 | 1 | 0 | 3 | |
| Referrals and Coordination | 77 | 2 | 6 | 2 | |
| Total | 207 | ||||
| Domain Two: Community-based palliative care | Accompaniment to Medical Appointment | 72 | 1 | 1 | 1 |
| Access to Interdisciplinary Care | 35 | 1 | 2 | 2 | |
| Counselling and Psychosocial Support | 25 | 1 | 0 | 1 | |
| Capacity Building and Partnership Development | 9 | 0 | 2 | 2 | |
| Patient Advocacy and Health Outcomes | 59 | 1 | 2 | 2 | |
| Total | 200 | ||||
High frequency: 10 + events.
Moderate frequency: 2–9 events.
Low frequency: 0–1 events.
Specific activities completed most often by the health navigator included booking a taxi or medical transportation (10), applying for transportation coverage (11), applying for a medical necessities benefit through provincial social services programs (12), advocating for a patient in their application for housing (14), connecting individuals to a local hospice grocery program (17), coordinating with specialists (23), providing counselling to patients and their loved ones (25), picking up and delivering medication (32), attending case conference meetings (52), and attending an appointment with a patient (69) (Table 2).
Discussion
This study adds to a growing body of literature characterizing the role of a health navigator in community-based palliative care and fills a gap in the area of impact measurement. We highlight the ways in which a health navigator with a background in social work can take a focused approach to the social determinants of health to facilitate access to equitable care at the end of life.
Emerging research offers similar emphasis on addressing the social determinants of health to improve access to palliative care for people living with life limiting illness and experiencing structural vulnerability,3–5,23 including through harm-reduction strategies25–29 and better integration of social services with health care services.21,30–32 We argue that addressing the social needs of patients and providing a person-centered approach to care is of considerable value not only in the field of socially-oriented palliative care for structurally vulnerable populations but in all fields of healthcare delivery. In fact, it is now widely recognized that addressing the social determinants of health is vital for improving overall health and reducing health disparities.33,34 For community-based palliative care teams that identify a gap in meeting the social needs of their patient population and wish to establish a health navigator position, we also provide an objective framework for evaluating the impact of a professional health navigator in community-based palliative care settings with the use of key performance indicators (KPIs).
Previous studies examining the impact of social workers and health navigators on the delivery of palliative care have focused primarily on outcomes such as pain management, advanced care planning documentation, and hospice utilization.15,17,18 In contrast to the existing literature, our study is unique in its measurement of outcomes pertaining to the social determinants of health. By examining the rates at which these outcomes were completed during the study period, we found that a high degree of output was required from the health navigator to achieve meaningful outcomes related to social needs (Supplemental File 1). For instance, the completion of 28 activities related to housing (i.e. housing applications and related advocacy) led to two successful housing applications during the study period, which although representative of a small number of outcomes, presumably led to considerable impact on the health and wellbeing of those patients who were housed in the context of a life-limiting illness. Given the well-documented challenges of overcoming structural barriers to facilitating dignifying and equitable end-of-life care, we encourage teams to acquire adequate and sustainable funding for a professional health navigator to maximize their potential impact.5,21,31
This study was limited by the fact that we had no baseline data or control group for comparison. Therefore, although we can postulate that a professional health navigator had a positive impact on access to palliative care delivered to this population, we cannot comment on the degree to which various outcomes related to the social determinants of health would have been achieved in the absence of a health navigator. Likewise, these findings may not be broadly applicable to other communities within a different health network if the specific needs of the population in question differ considerably from the population we studied. Certain outcomes were achieved at a lower rate than anticipated, which may speak to the difficulty of measuring these outcomes, highlight an area for role development, or it may indicate that a longer study period is needed to capture outcomes that were achieved at low frequency over the course of 1 year of data collection.
This study opens the door for future avenues of research to enrich our understanding of the potential for a health navigator to enhance the delivery of palliative care to structurally vulnerable populations as well as those accessing “mainstream” community-based palliative care services. Future directions may include measuring the impact of a health navigator on quality of care, patient outcomes, survival, and cost savings for the healthcare system as a result of addressing the social determinants of health.
Supplemental Material
Supplemental material, sj-pdf-1-pmj-10.1177_02692163221146812 for Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation by Lilian Robinson, Leeann Trevors Babici, Alissa Tedesco, Donna Spaner, Trevor Morey and Naheed Dosani in Palliative Medicine
Acknowledgments
We would like to acknowledge all members of the Palliative Education and Care for the Homeless Program for reviewing this manuscript and for their endless dedication to providing palliative care to structurally vulnerable populations. Team members include Dr. Naheed Dosani, Dr. Alissa Tedesco, Dr. Donna Spaner, Dr. Antoinette Mihaylova, Dr. Daniel Rosenbaum, and Sasha Hill (Palliative Care Nurse Coordinator).
Footnotes
Authorship: All authors made a substantial contribution to the design of this work as well as the acquisition, analysis, and interpretation of data. All authors either drafted or critically revised this article, approved the version to be published, and have participated sufficiently in the work to take public responsibility for appropriate portions of the content.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics: This research was approved by the Inner City Health Associates health research oversight committee.
Consent and data sharing: No participant data was used and therefore no consent was obtained. All data was quantitative in nature and stored in an anonymous spreadsheet with no corresponding participant identifiers.
ORCID iD: Lilian Robinson 
https://orcid.org/0000-0003-0614-450X
Supplemental material: Supplemental material for this article is available online.
References
- 1.City of Toronto Housing & Homelessness Reports. Street needs assessment 2021, https://www.toronto.Ca/legdocs/mmis/2021/ec/bgrd/backgroundfile-171729.pdf (2021, accessed 1 March 2022).
- 2.Khandor E, Mason K.The street health report 2007. Report, Street Health in Partnership with the Wellesley Institute, September2007. https://www.streethealth.ca/downloads/the-street-health-report-2007.pdf (2021, accessed 2 March 2022).
- 3.Cheung AM, Hwang SW.Risk of death among homeless women: a cohort study and review of the literature. CMAJ 2004; 170: 1243–1247. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Hwang SW.Mortality among men using homeless shelters in Toronto, Ontario. JAMA 2000; 283: 2152–2157. [DOI] [PubMed] [Google Scholar]
- 5.Stajduhar KI, Mollison A.Too little too late: how we fail vulnerable Canadians as they die and what to do about it. Report for the Equitable Access to Care Study, Victoria, British Columbia, November2018. [Google Scholar]
- 6.Freeman HP, Muth BJ, Kerner JF.Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract 1995; 3: 19–30. [PubMed] [Google Scholar]
- 7.Natale-Pereira A, Enard KR, Nevarez L, et al. The role of patient navigators in eliminating health disparities. Cancer 2011; 117 (15 Suppl): 3543–3552. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Frelix GD, Rosenblatt R, Solomon M, et al. Breast cancer screening in underserved women in the Bronx. J Natl Med Assoc 1999; 91: 195–200. [PMC free article] [PubMed] [Google Scholar]
- 9.Ell K, Padgett D, Vourlekis B, et al. Abnormal mammogram follow-up: a pilot study women with low income. Cancer Pract 2002; 10: 130–138. [DOI] [PubMed] [Google Scholar]
- 10.Hiatt RA, Pasick RJ, Stewart S, et al. Community-based cancer screening for underserved women: design and baseline findings from the breast and cervical cancer intervention study. Prev Med 2001; 33: 190–203. [DOI] [PubMed] [Google Scholar]
- 11.Burhansstipanov L, Wound DB, Capelouto N, et al. Culturally relevant “navigator” patient support. The Native Sisters. Cancer Pract 1998; 6: 191–194. [DOI] [PubMed] [Google Scholar]
- 12.Weinrich SP, Boyd MD, Weinrich M, et al. Increasing prostate cancer screening in African American men with peer-educator and client-navigator interventions. J Cancer Educ 1998; 13: 213–219. [DOI] [PubMed] [Google Scholar]
- 13.Friedell GH, Rubio A, Maretzki A, et al. Community cancer control in a rural, underserved population: the Appalachian Leadership Initiative on Cancer Project. J Health Care Poor Underserved 2001; 12: 5–19. [DOI] [PubMed] [Google Scholar]
- 14.Cancer Care Ontario. Aboriginal cancer strategy II - annual report 2012-2013. Staying on the path. 2013. https://www.cancercareontario.ca/sites/ccocancercare/files/assets/CCOAboriginalStrategy2.pdf?redirect=true (2013, accessed 4 March 2022).
- 15.Fischer SM, Cervantes L, Fink RM, et al. Apoyo con Cariño: a pilot randomized controlled trial of a patient navigator intervention to improve palliative care outcomes for Latinos with serious illness. J Pain Symptom Manag 2015; 49: 657–665. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Pompili A, Telera S, Villani V, et al. Home palliative care and end of life issues in glioblastoma multiforme: results and comments from a homogeneous cohort of patients. Neurosurg Focus 2014; 37: E5. [DOI] [PubMed] [Google Scholar]
- 17.Stein GL, Cagle JG, Christ GH.Social work involvement in advance care planning: findings from a large survey of social workers in hospice and palliative care settings. Palliat Med 2017; 20: 253–259. [DOI] [PubMed] [Google Scholar]
- 18.O’Donnell AE, Schaefer KG, Stevenson LW, et al. Social worker-aided palliative care intervention in high-risk patients with heart failure (SWAP-HF): a pilot randomized clinical trial. JAMA Cardiol 2018; 3: 516–519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Blacker S, Deveau C.Social work and interprofessional collaboration in palliative care. Prog Palliat Care 2010; 18: 237–243. [Google Scholar]
- 20.Palliative Outreach Response Team (PORT). Equity in palliative approaches to care. 2019. https://www.equityinpalliativecare.com/port (accessed September 2020).
- 21.Reimer-Kirkham S, Stajduhar K, Pauly B, et al. Death is a social justice issue: Perspectives on equity-informed palliative care. Adv Nurs Sci 2016; 39: 293–307. [DOI] [PubMed] [Google Scholar]
- 22.Dohan D, Schrag D.Using navigators to improve care of underserved patients: current practices and approaches. Cancer 2005; 104: 848–855. [DOI] [PubMed] [Google Scholar]
- 23.Hwang S, Dowbor T, Devotta K, et al. Palliative care services for people experiencing homelessness in Toronto, a preliminary needs assessment. Report, Centre for Urban Health Solutions Survey Research Unit, St. Michael’s Hospital, May2017. [Google Scholar]
- 24.Change Foundation. Health system navigators: band-aid or cure. https://changefoundation.ca/wp-content/uploads/2016/05/TCF_Panorama_Navigator_final.pdf (2013, accessed October 2020).
- 25.Cagle JG.Weathering the storm: palliative care and elderly homeless persons. J Hous Elderly 2009; 23: 29–46. [Google Scholar]
- 26.Collier R.Bringing palliative care to the homeless. CMAJ 2011; 183: E317–E318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.McNeil R, Guirguis-Younger M, Dilley LB.Recommendations for improving the end-of-life care system for homeless populations: a qualitative study of the views of Canadian health and social services professionals. BMC Palliat Care 2012; 11: 14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Ferrell BR, Twaddle ML, Melnick A, et al. National consensus project clinical practice guidelines for quality palliative care guidelines, 4th edition.J Palliat Med 2018; 21: 1684–1689. [DOI] [PubMed] [Google Scholar]
- 29.Hudson H, Perron A, Wright D.Palliative care and the injustice of mass incarceration: critical reflections on a harm reduction response to end of life behind bars. Can J Crit Care Nurs 2019; 1: 4–16. [Google Scholar]
- 30.Henry B, Dosani N, Huynh L, et al. Palliative care as a public health issue: understanding disparities in access to palliative care for the homeless population living in Toronto, based on a policy analysis. Curr Onocol 2017; 24: 187–191. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Stajduhar KI, Mollison A, Giesbrecht M, et al. “Just too busy living in the moment and surviving”: barriers to accessing health care for structurally vulnerable populations at end-of-life. BMC Palliat Care 2019; 18: 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Stajduhar KI, Giesbrecht M, Mollison A, et al. “Everybody in this community is at risk of dying”: an ethnographic exploration on the potential of integrating a palliative approach to care among workers in inner-city settings. Palliat Support Care 2020; 18: 670–675. [DOI] [PubMed] [Google Scholar]
- 33.Health Disparities Task Group of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security. Reducing health disparities – roles of the health sector: discussion paper. http://www.phac-aspc.gc.ca/ph-sp/disparities/pdf06/disparities_discussion_paper_e.pdf (2004, accessed September 2022).
- 34.Canadian Medical Association. Health equity and the social determinants of health: a role for the medical profession: CMA policy. https://policybase.cma.ca/link/policy10672 (2013, accessed September 2022).
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental material, sj-pdf-1-pmj-10.1177_02692163221146812 for Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation by Lilian Robinson, Leeann Trevors Babici, Alissa Tedesco, Donna Spaner, Trevor Morey and Naheed Dosani in Palliative Medicine