The Impact of a Community Resource Navigator Program on Patient Trust

Abstract

Background:

Addressing patients’ non-medical needs has become a focal point in primary care research and practice. Programs such as the Center for Patient Partnerships’ Community Resource Navigator Program address social determinants of health by connecting participants to community-based resources in an effort to ameliorate unmet social needs.

Methods:

27 interviews were conducted with program participants to assess improvements in social needs and trust with the health care system as a result of the program.

Results:

Participants in the program reported increased trust in their provider or health system, improved health and confidence in self-advocacy.

Discussion:

Findings suggest that in addition to providing crucial support to address participants’ unmet social needs, navigation programs have the co-benefit of enhancing their relationship with the clinic and health system.

Background

It is well understood that social determinants of health impact 40–90% of health outcomes^1,2.Primary care clinics are increasingly recognized as being uniquely positioned to address patients’ non-medical needs and thereby improve health^3,4. Among other initiatives, clinics are turning to patient navigator programs to better support the populations they serve. Many navigation programs are modeled after Health Leads, originally Project HEALTH at Boston Medical Center. The Health Leads model trains undergraduate students to assist families with unmet social needs⁵. The Center for Patient Partnerships, housed within the University of Wisconsin Law School, started the Community Resource Navigator Program (Navigator Program) in 2016. This program, modeled after Health Leads, intends to address a lack of support services for patients with social barriers in an otherwise well-resourced health system in Madison, WI. Social needs screeners (Figure 1) are distributed by clinic receptionists and completed by patients, who then agree or decline to be paired with a student navigator as a part of the program. Patient navigators counsel participants thorough barriers of the health system and social services that disproportionately burden underserved groups⁶. They help to facilitate communication and cooperation between patients and their providers, increase health insurance literacy, as well as ensure improved health care access and compliance by addressing logistical needs such as transportation⁶. The Program can ultimately assist the patient to locate and access valuable resources, and also to improve the relationship between that patient and their clinical team. Initiatives like the Navigator Program have proven effective on a national level, most evident in pediatrics and oncology literature^4,6,7.

Figure 1:

Social Needs Screener

Methods

Program Description:

This interview-based evaluation was designed to assess the role navigator programs can play in an individual’s ability to access community resources and in developing trust between participants and the healthcare system. This project was conducted through a partnership between the UW Center for Patient Partnerships and the UW Population Health Institute.

Participants and Eligibility:

All possible participants were patients of the clinic who had completed a standardized social determinants of health screener (Figure 1) and agreed to assistance from the Navigator Program. Eligibility was not further limited.

Recruitment:

Navigator Program records were used to identify the potential pool of participants: every-other open case and every tenth closed case were chosen to total 242 potential participants. Recruitment letters were sent by mail in preferred languages. 28 individuals contacted the researcher, 2 declined to be interviewed. 26 semi-structured interviews took place in person or by phone. Interviews covered: participants’ general thoughts about the program, perceived changes in interactions or communication with health care providers, and perceived changes in resource access, individual behaviors, attitudes, and beliefs. With participant consent, interviews were audio-recorded. Interviews were transcribed and field notes were taken to inform analysis. Participants received a $20 incentive.

Data Analysis:

Interview transcripts were coded using pre-identified codes to identify emergent themes. Dedoose® qualitative coding software was used to index ideas and group themes. Demographic data was compiled using Microsoft Excel.

All work detailed above was conducted by one medical student, with support from supervisors.

Results

26 interviews were conducted with 27 people, one interview was conducted with a couple and their responses were collated into one data point (except for distinct demographic data). 8 interview participants had not yet been contacted or had not yet received resources from the Program. Responses specific to this group are calculated separately where appropriate. Table 1 shows demographic characteristics for participants, including duration and depth of experiences with the Navigator Program and clinic providers, and social needs pathways used.

Table 1:

Participant Demographics

	N (%)
Age (years)
18–49	14 (52)
50–79	13 (48)
Gender Identity
Male	7 (26)
Female	20 (74)
Race/Ethnic Identity
African	4 (15)
African American	8 (30)
Caucasian	11 (41)
Hispanic	1 (4)
Other	7 (26)
Not provided	1 (4)
Primary Language
English	25 (93)
Spanish	1 (4)
Igbo	3 (11)
Years of Education
< 12th grade	5 (19)
12th grade/GED equivalent	5 (19)
Some college	7 (26)
Associates degree or higher	10 (37)
Employment Status
Employed	10 (37)
Unemployed	9 (33)
Disability	5 (19)
Retired	3 (11)
Housing Status
Rent	18 (67)
Own	7 (26)
Lives with family	2 (7)
Homeless	0 (0)
Number of Children
0	7 (27)
1–3	11 (42)
> 4	8 (31)
Time in Navigator Program
1–6 months	14 (52)
7–12 months	10 (37)
> 12 months	3 (11)
Number of Contacts with Program
< 5	13 (48)
5–15	11 (41)
> 15	3 (11)
Time with Provider
1–3 years	16 (59)
4–10 years	4 (15)
> 10 years	5 (19)
Unknown	2 (7)
Insurance Status
Private	6 (22)
Public	17 (63)
Public + Supplement	4 (15)
None	0 (0)
Social Needs Pathways Used *
Legal	3
Housing	7
Food	13
Transportation	9
Children (activities, household needs)	2
Utilities	4
Dental and Medical (incl. insurance)	6
Other (work, school, outings)	8
2 pathways used	6
> 2 pathways used	6
Average number of pathways per person	2

^*Percentages not calculated due to multiple pathways utilized per person

Participants’ responses are collected in detail in Table 2, which enumerates the number and proportion of those who answered a selection of questions pertinent to the aims of this study. Overall, most participants (81%) gave a positive review of the Program, acknowledging the general sense of support it provided. All participants included in the group who had received resources (19 people), reported an improvement in their level of need for their respective concerns. From a logistical perspective, 71% of participants were happy with the location of the Navigator Program within their community clinic, citing that it was convenient and any established connection they already had with the clinic helped to facilitate involvement in the program. One participant thought it was the only place that made sense for a program of its type, noting that it was always their expectation that doctors’ offices would provide this type of support.

Table 2:

Participant Responses to Select Interview Questions

	Improvement N (%)	Maintenance	Decline
Connection to health care provider	7 (50)	7 (50)	0 (0)
Connection to clinic/health system	10 (67)	5 (33)	0 (0)
Perception of health system	14 (88)	2 (12)	0 (0)
Impact of program on quality of life	22 (85)	4 (15)	0 (0)
Impact of program on overall health	14 (93)	1 (7)	0 (0)
Impact of program on personal value	25 (96)	0 (0)	1 (4)

Note: All responses reflect participants’ perceived improvement, maintenance or decline of their status respective of the questions posed throughout the interview.

Most notably, improved connection to the health care system, the clinic, and individual providers was a strong impact of the Program. Participants indicated that the improved relationship was due to increased empowerment they garnered from the Navigator Program to take charge of their own care and advocate for themselves in their clinic visits. In addition, the aforementioned physical link between the Program and the clinic was important, emphasized by participants who expressed they felt the clinic was doing more for them than simply taking care of their medical needs, which helped build trust. Further, 88% of those interviewed acknowledged an improved perception of the larger health system as a result of the Program.

Most participants reported benefit to their overall quality of life: some spoke to empowerment and improved security; others cited multifaceted assistance of specific resource support, such as food vouchers; additional benefits included the alleviation of financial burden and new community connections. Notably, 93% of participants perceived improved overall health as a result of the Program, acknowledging better mind-body connection, improved access to healthier food, increased exercise, and less depression. Participants also cited heightened confidence in their ability to comply with provider expectations and increased access to appointments. Confidence in this program was evident when 92% of interviewees said they would refer it to others.

Those who had not yet received resources were among those who acknowledged the positive presence the screening tool provided and anticipated benefits the Program would bring them. However, due to the delay in contact, one person felt forgotten and this group was unsure about referring anyone to the Program since they had not experienced it first-hand.

Discussion

Patient experiences with the Community Resource Navigator Program were overwhelmingly positive. An important finding of this evaluation was that the majority of participants felt the Program strengthened their relationship with and perception of their provider, the clinic, and the healthcare system in general; this sentiment has borne out in related literature as well^6,7. Overall, the Program helped its participants feel more valued in numerous ways. Even those who had not yet received resources said that the presence of the social need screener made them feel as though someone wanted to help. The impact that a simple questionnaire had on those who received it highlights a lack of systemic support available to those in the community who need it most. With appropriate adjustments to this model, to better accommodate different communities, this program is one that has the feasibility to be implemented in clinics across Madison, Wisconsin.

This evaluation was limited by self-selection and recall biases. Those who participated in the study self-selected to participate by calling the evaluator and those in situations that prohibited contact potentially limited the full scope of results. Had more participants responded to the initial call for study involvement, a randomization scheme could have been used to help limit such bias. Recall bias is the second limitation of this evaluation as a result of interview-based data accumulation and analysis. Participants potentially reported higher levels of medical compliance and health improvement, for example, than might be represented in their medical health record. Chart review would help improve the accuracy of such claims.

Conclusion

Participants of the Program expressed their gratitude for its role in helping them gain access to resources, in elevating their confidence in navigating other aspects of their lives, and improved relationships with health care providers and the clinic. Heightened trust in providers and the system in general play a role in perceived health improvements, as elucidated by this report, and also have the opportunity to improve measurable targets of patient compliance and associated health outcomes⁴. In an ever-changing health care system, where patient experience and measurable health outcomes lead to improved reimbursement, programs such as these have the potential to serve as low-cost initiatives towards those goals. Programs modeled after navigator programs such as this one can continue to provide essential support to improve social determinants of health in such a way that can improve doctor-patient relationships and overall well-being.