Using Care Navigation to Improve Patient-Reported Outcomes Among Older Adult Patients: Preliminary Results From a Pilot Study

Abstract

Navigating health and social care in the United States can be difficult for people of all ages, but older adults often have multiple health problems, chronic illnesses, and disabilities that can increase the complexities of their care. To assist older adult patients and/or their caregivers with coordinating care, and providing information, advocacy, and resources, Henry Ford Health (HFH) implemented a Senior Care Navigation Program (SCNP). Older HFH patients or their caregivers were referred to the SCNP either by a provider or another member of their care team. A senior navigator (SN) then reached out to the patient/caregiver by telephone to discuss the SCNP and their support/care needs. The SN scheduled follow-up calls as needed. Patients/caregivers enrolled in Phase 1 of this pilot program were given the option to join the evaluation group. These patients were interviewed by an independent research interviewer at baseline, 3-, 6-, and 9-month post initial contact to complete 5 patient-reported outcomes measures. Our Phase 1 pilot has demonstrated significant improvements in the EQ5D (health-related quality of life) and two patient-reported outcomes measurement information system (PROMIS) measures (depression and anxiety) suggesting that the SCNP program at HFH is having a positive impact on older adult patients’ health and well-being. In Phase 2, we will further evaluate the impact of the SCNP on healthcare utilization.

Key Points

1. Patients and caregivers enrolled in the Senior Care Navigator Program receive assistance from a senior navigator who can advocate for the patient, assist with healthcare system navigation (including helping schedule appointments), and coordinate care opportunities by leveraging local community partners and services.

2. Patients and caregivers enrolled in the Senior Care Navigator Program experienced significant improvements in the EQ5D (health-related quality of life) and two patient-reported outcomes measurement information system (PROMIS) measures (depression and anxiety).

3. Through qualitative feedback, patients and caregivers reported only positive experiences partaking in the Senior Care Navigator Program and noted that the program filled a much-needed gap in supporting older adults with their health as they continue to age.

Introduction to the Issue/Problem/Challenge

The U.S. population is aging rapidly, with estimates that by 2030, older adults will make up 21% of the population, up from the ∼15% they currently represent. ¹ By 2034, they will outnumber children for the first time in U.S. history. ¹ As the proportion of older adults increases in the years that follow, so will their need for care. At risk for complex health problems, chronic illness, and disability,^2,3 older adults are the heaviest users of healthcare. ⁴

Declines in marriage, increases in divorce, and lower fertility ² also mean that more people will reach older adulthood without a spouse or adult child to rely on for their care needs. Given that traditional family caregivers provide most of the care/support that enables older adults to navigate their healthcare and live independently, a rise in the number of older adults, coupled with a shrinking pool of traditional caregivers is likely to result in poorer health outcomes for older adults and increased healthcare costs. ²

Introduced in the early 1990s, patient navigation programs (PNPs) have been employed to help address inequitable access to care for patients with cancer. ⁵ Designed to help “guide patients through the health care system and overcome barriers that prevent them from getting the care they need,” ⁶ PNPs targeting other at-risk patient populations ⁷ have emerged, including PNPs to support older adults and their caregivers. ⁸ However, to date, such programs have not been widely employed within healthcare systems due to siloed care sector organization, health system culture, and funding-related barriers. ⁸ Instead, care coordination (CC; organizing and coordinating a patient's care across multiple providers and care settings) ⁹ has received greater attention. Although benefits such as improved quality of care and reduced hospital usage are reported,^10,11 CC is often limited to the administrative and logistical aspects of a patient's care. Thus, with a broader focus on attending to all aspects of a patient/caregiver's needs (eg, coordination, information, advocacy, self-management of health, and emotional support), ¹² PNPs may be better suited to holistically support older adult patients/caregivers in navigating their care and warrant further investigation.

This paper provides an overview of Phase 1 of a pilot PNP for older adults and their caregivers that was initiated in June of 2021 at Henry Ford Health (HFH) in Michigan, USA, and highlights initial evidence of its impact.

Intervention

Housed in the Department of Care Experience, the Senior Care Navigation Program (SCNP) is a donor-funded program, being piloted at 4 donor-selected HFH clinics in West Bloomfield Township, aimed at assisting older adult patients/caregivers lacking traditional support by providing information, advocacy, navigation, and access to resources. As per the donor's request, the SCNP adopts a broad and inclusive definition of older adulthood, enabling patients/caregivers aged 50 years or older access to the SCNP.

SNs are certified community health workers with additional qualifications in advanced care planning who act as a single point of contact for patients/caregivers and are trained to advocate on their behalf, assist with healthcare system navigation (including helping schedule appointments), coordinate care opportunities by leveraging local community partners/services, and capture older patient/caregiver needs to further develop patient and caregiver programs. SNs are integrated into the care teams at each clinic and work with the care team to holistically address patient/caregiver needs. For example, if the SN needs to advocate on the patient/caregiver's behalf about a particular need, they can communicate directly with the relevant member of the care team (eg, case management, physician, and nurse).

SNs undergo an extensive onboarding process which includes reviewing relevant policies and procedures, computer/electronic health system (electronic health record [EHR]) training, touring clinics and meeting office staff, online educational classes, and regular check-in meetings with the Program Manager and Director (see Figure 1a for the SCNP's structure). Most importantly, SNs undergo extensive training regarding the availability of hospital, social, and community-based resources at their disposal.

Figure 1.

Governance structure and overview of a patient's journey through the Senior Care Navigator Program, including program evaluation. Note. *Optional program evaluation touchpoints.

Program Overview and Patient Journey

Older adult patients/caregivers who need support navigating their health or health/social care systems (eg, emotional support and social determinants of health) and who could benefit from the SCNP are identified by their primary care provider or a member of the primary care team (eg, nurse manager and physician assistant; Figure 1b). The primary care provider (or team member) will discuss the SCNP with the patient/caregiver and ask them if they would like a referral. If the patient/caregiver expresses interest, the referral is sent to the SN via the EHR system, email, telephone, or in person. Referral criteria are purposefully broad and only require the patient/caregiver to meet the age requirement and have a need for navigational support, as identified by the care team. Alternatively, during in-clinic days, SNs also host a table of resources for the SCNP and can be approached by older adult patients/caregivers who self-identify a need for support. In this case, the SN is able to enroll the patient/caregiver by speaking with their care team and asking them to complete a referral.

Once the SN receives a referral, they will contact the patient/caregiver via telephone. During the initial telephone call, the SN will provide a detailed overview of the SCNP and collect information from the patient/caregiver regarding their support/care needs. Once needs are identified, the SN will work with the patient/caregiver to establish a support/care plan. Should the patient/caregiver need and/or desire additional or ongoing support, the SN will schedule subsequent follow-up calls. If and when all care/support needs are addressed, the patient/caregiver's participation in the program ends, with the caveat that they may rejoin the program should any additional needs arise. If needs are outside the scope of the SCNP (eg, hospice care and insurance-related concerns), the SN will connect the patient/caregiver with the provider or program that is qualified to address such needs. A flowchart of the program's protocol and the patients’ journey through the program is provided in Figure 1b.

Program Evaluation

Target enrollment for Phase 1 of the SCNP's pilot is 50 patients/caregivers. The goals of Phase 1 of the SCNP pilot are (a) gauge interest/need/acceptability for SCNP, (b) test/refine protocols, processes, and methods, and (c) gather initial data regarding SCNP's impact on patient-reported outcomes (PROs) among users.

As part of Phase 1 of the program's evaluation, SCNP users are asked to complete optional telephone-administered surveys at 4 time points (ie, baseline and 3-, 6-, and 9-month post initial contact). During each telephone survey, patients/caregivers complete 5 PRO measures with the research interviewer, including the EQ5D (health-related quality of life) and 4 PROMIS measures (emotional, depression, anxiety, and self-efficacy). Demographic information is also collected during the first touchpoint. Additionally, during the last touchpoint patients/caregivers are given the chance to provide feedback about the program. For those not partaking in the program evaluation, the same opportunity to provide feedback is available during their wrap-up call with the SN. The program evaluation is facilitated by researchers from the Department of Public Health Sciences including epidemiologists, a biostatistician, and a research interviewer.

Ethical approval was received from HFH's Institutional Review Board and all program evaluation procedures were conducted in accordance with approved protocols. Verbal informed consent was obtained from participants for their anonymized information to be published in this article.

Evidence of Impact

As of December 2023, 281 individuals have utilized the SCNP, with 52 individuals (n = 47 patients and n = 5 caregivers; 73% female, mean age = 74.3 years, age range: 56–94 years) participating in the program evaluation. All participants have completed the baseline survey. Of those eligible for survey completion, 39 out of 43 (91%) have completed the 3-month survey, 30 out of 38 (77%) have completed the 6-month survey, and 26 out of 37 (70%) have completed the 9-month survey.

Follow-up surveys (3-, 6-, and 9-month) were compared to baseline surveys using paired t-tests (Table 1). No differences in EQ5D or any PROMIS measures were observed when comparing 3-month to baseline responses. For participants with a 6-month follow-up, significant improvements in the EQ5D, as well as PROMIS depression and anxiety scores were noted. For participants with 9-month follow-ups, there was a significant improvement in PROMIS depression and a trend for EQ5D.

Table 1.

Comparing Participants Responses at 3-, 6-, and 9-month to Baseline (Means and Standard Deviations Provided).

Variable	Baseline	Follow up	Change from baseline1	p-value
Baseline versus 3 months (n = 39)
EQ5D health today	68.1 ± 27.3	70.3 ± 24.0	1.5 ± 29.9	.755
PROMIS emotional	53.7 ± 8.2	54.8 ± 7.2	1.1 ± 8.5	.427
PROMIS depression	51.6 ± 8.7	52.5 ± 10.0	0.9 ± 6.9	.423
PROMIS anxiety	54.0 ± 9.8	52.1 ± 10.8	−1.9 ± 10.0	.238
PROMIS self-efficacy	39.9 ± 8.4	38.7 ± 7.3	−1.2 ± 7.1	.311
Baseline versus 6 months (n = 30)
EQ5D health today	68.5 ± 30.0	78.7 ± 16.5	9.8 ± 25.3	.0462
PROMIS emotional	53.9 ± 8.5	54.8 ± 7.7	0.9 ± 10.0	.638
PROMIS depression	51.1 ± 8.1	47.2 ± 7.9	−3.9 ± 7.8	.0112
PROMIS anxiety	53.2 ± 9.8	49.0 ± 8.6	−4.2 ± 9.7	.0232
PROMIS self-efficacy	40.1 ± 7.9	39.7 ± 7.4	−0.7 ± 7.8	.612
Baseline versus 9 months (n = 26)
EQ5D health today	71.2 ± 29.7	83.4 ± 12.8	11.9 ± 29.2	.053
PROMIS emotional	53.9 ± 8.6	54.7 ± 7.9	0.8 ± 9.9	.681
PROMIS depression	50.9 ± 8.2	47.5 ± 7.1	−3.4 ± 5.9	.0062
PROMIS anxiety	53.0 ± 10.4	51.6 ± 8.4	−1.4 ± 11.1	.523
PROMIS self-efficacy	40.7 ± 8.4	40.6 ± 8.2	−0.2 ± 8.7	.909

Abbreviation: PROMIS, patient-reported outcomes measurement information system

Note. ¹Change was computed as follow-up time minus baseline. ²p< .05.

Feedback provided by patients/caregivers during the final phone call or who have wrapped up their communication with an SN (ie, identified support/care needs addressed) has been extremely positive. SNs have been praised for being “very helpful” and “knowing what they are talking about.” Patients/caregivers also praised the SCNP as a whole and suggested that the information, resources, and services provided are much needed and that the program deserves an “A++” rating. Many also noted that they would highly recommend the program and that they “can’t say enough [good things] about the program.”

Future Directions

Phase 2 of the SCNP, whereby program evaluation enrollment is expanded to 150 patients/caregivers, is currently underway. In hopes of increasing program evaluation enrollment, patients/caregivers in Phase 2 are being compensated $25 for each phone survey (compensation was not provided in Phase 1).

As part of this phase, the SCNP is also conducting needs assessments at other clinics to identify locations for program expansion and working with HFH's Community Health, Equity, and Wellness Network to enroll the SNs as registered Medicaid and Medicare providers so that their services can be billed for, creating long-term financial sustainability for the SCNP.

We will continue to test/refine the program's protocols, processes, and methods and conduct telephone surveys to evaluate the program's impact on PROs and acceptability among users. For example, we plan to collect additional sociodemographic information and patient characteristics (eg, diseases, comorbidities, and treatments) in the future to better understand who is using the program and how a patient's health status may impact their ability to complete the follow-up surveys.

We will also be conducting a pre–post comparison of healthcare utilization among enrolled patients using EHR data (eg, readmission rates, emergency department visits, and hospitalization rates, along with rates of outpatient visits/procedures) and comparing SCNP users to a historical comparison group to evaluate healthcare utilization. Results from both phases of the pilot will be used to help lobby HFH to continue support for the program, even after donor funding expires.

Conclusions

At-risk patient populations, such as older adults, often struggle to navigate their health, as well as health and social care systems. HFH's SCNP supports older adult patients/caregivers with their care by providing information, advocacy, navigation, and access to resources. Preliminary results from pilot Phase 1 of the SCNP suggest that there is a need for such a program and that there is initial acceptability among users. Moreover, among a small sample, the program is having a positive impact on older adult patients/caregivers’ health and well-being. Our program may help inform and guide the establishment of future navigation programs for older adults for other health systems and institutions.