Background
Method
Context – A detailed description of the diabetes navigation program
Program leadership
Program recruitment
Process evaluation
Sample
Data collection
1. In your own words, what is diabetes navigation? | |
2. What qualities make a good diabetes navigator? | |
3. How might diabetes navigation help patients struggling with their diabetes management? | |
Probe: Please provide examples of diabetes navigation successes. | |
4. Please describe your experience with diabetes navigation at the Diabetes Endocrine Center? | |
Probe: How does diabetes navigation help providers in the Diabetes Endocrine Center? | |
Probe: How does diabetes navigation not help providers in the Diabetes Endocrine Center? | |
6. What barriers have you experienced with diabetes navigation? | |
7. What is needed to improve the diabetes navigation program at the Diabetes Endocrine Center? | |
Probe: What is the diabetes navigation program doing well? | |
Probe: What is the diabetes navigation program not doing well? | |
Probe: How do you propose we improve the diabetes navigation program? | |
8. Do you have any other comments or suggestions about the diabetes navigation program? |
Data analysis
Rigor
Results
Participants n (%) | |
---|---|
Age (years) | 44.7 ± 11.6 |
Gender | |
Female | 14 (82.4) |
Male | 3 (17.6) |
Race | |
White/Caucasian | 16 (94.1) |
Mixed | 1 (5.9) |
Position | |
Navigator | 5 (29.4) |
Provider | 5 (29.4) |
Administrator | 4 (23.5) |
Office Staff | 3 (17.6) |
Work experience (years) | 13.3 ± 9.6 |
Design
Fidelity of implementation
GOAL: We will establish a Comprehensive Diabetes Patient Navigation Program for Rural Appalachians to improve health outcomes and lower health care expenditures for individuals with diabetes through the development and coordinated implementation of the Diabetes Patient Navigator Program to impact the health care delivery system, individual patients, and inform policy. | ||||
Objective One: Establish a Diabetes Patient Navigator Program that serves individuals with diabetes to improve health measures in diabetes clients by addressing barriers to health care and self-care activities Evaluate Annually: # provider/staff trained to identify and refer patients with diabetes due to poor glycemic control; number of referrals received, % of referred individual who engage navigation services; number and type of barriers identified; number of barriers targeted for interventions; number of barriers resolved; repeated measures of patient health metrics including haemaglobin, blood pressure control (all available), depression symptoms, distress symptoms, self-care (intake, 6 m, 12 m); provider and patient satisfaction (annual). Patient admissions, readmissions and emergency department utilization, annual expenditures; patient improvement measures tracked. Healthy People 2020: Improve glycemic control; improve blood pressure control; complete dental, eye, foot exams; increase number performing daily self-monitoring of glucose and getting formal diabetes education. | ||||
Activities Year One: October 2015–October 2016 | Dates | Outcome/Results | Evaluation/Measurement | Partner Responsible |
Year 1, Activity 1: Design intake, referral procedures, HIPAA compliant releases at Diabetes Endocrine Center (SYSTEM CHANGE) | May 2015–July 2015 | • Intake and referral processes in place; staff trained • Navigator to serve Diabetes Endocrine Center • Obtain access EHR at both | • Workflow within health care practice is reformed to screen and refer patients to Diabetes Navigator • Number staff trained • Referrals made | Diabetes Navigators; Medical practice managers |
Year 1, Activity 2: Submit protocol to IRB for approval; consent process established (EVALUATION) | August 2015–September 2015 | • Consent forms and measurement tools selected • Data collection processes set | • IRB approval received | Principal Investigator |
Year 1, Activity 3: Direct services provided to individuals referred to Diabetes Navigator. (INDIVIDUAL CHANGE) | October 2015–October 2016 | • 80% of patient referred are successfully engaged in Navigation services • 90% barriers targeted for intervention that the consumer agreed to address with the Navigator are resolved. | • Process: number and types barriers identified and resolved. Goal to see 50 patients. • Health Outcomes: haemoglobin A1C, blood pressure, exams depression, distress, self-efficacy, satisfaction metrics 3 times year • Cost Outcomes: admissions, readmissions, and ED utilization rates tracked; annual expenditures | Diabetes Navigators |
Year 1, Activity 4: Manager of Navigator Program facilitates the coordination of all navigation programs (SYSTEM CHANGE) | October 2015–October 2016 | • Protocols and policies in place to differentiate types of navigation services and access • Best linkages of care for patients | • System integration increases the capacity and efficiency of service delivery; Single point of referral established | Diabetes Navigators |
Years 1,2,3, Activity 5: Diabetes nurse navigators initiate clinical activity to become Certified Diabetes Educator | Jan 2015-April 2018 | • Clinical hours accrued | • Certified Diabetes Educator earned at end of Year 3 | Diabetes Navigators |
Year 1, 2, 3; Activity 6: Diabetes Navigator and manager participate in consortium members meeting to discuss integration efforts, monitor challenges, improve practices; facilitate integration into Diabetes Institute; develop five year strategic plan. | October 2015–April 2018 | • Consortium meetings held quarterly • Strategic planning sessions held • Integration of consortium into larger delivery system and Diabetes Institute | • 100% attendance • Steps identified to integrate with Diabetes Institute • Five year strategic plan written such that it situates to strategic initiatives of consortium partners; and adopted by consortium | Diabetes Navigators, Principal Investigator |
The role of the navigator
Theme 1: The navigator addresses sources of health disparities
“Navigation from the stance of a registered nurse is meeting clients where they are in their stage of development and health, and providing them with the tools they need to optimize outcomes. I think navigation involves assessing needs in their social life, in their medical life, mental health, social determinants of health issues, all of those things I think come into play…With our clients, we find that many have no housing or poor housing, substandard housing. Some are in unsafe situations. Some have food insecurity. Some have difficulty with transportation. Some have educational barriers including an inability to read medical text or forms. Some have no insurance, no money to get things that aren’t covered by Medicaid, a lot live in risky environments. Many have substance abuse.” [ID 9, Navigator].
“Diabetes is a pretty complex condition. There’s obviously certain clinical, individualized types of needs somebody has with diabetes, but beyond that diabetes touches so many parts of your lives. To be able to manage diabetes, you have to sometimes have assistance beyond some of the clinical – standard clinical types of care. So, to me, diabetes navigation is filling in all the other holes left to manage diabetes beyond clinical care.” [ID 6, Health Administrator]
“I see Diabetes Navigation as helping stand in the gap between services as usual that are available through standard medical practice and the other aspects of our life that directly impact our quality of life, and our health, and our ability to make it day-to-day. And I see the Diabetes Navigators as helping folks navigate that intersection between what they need to do for their medical health, but also how that interfaces with their day-to-day lives and the multiple stressors they meet.” [ID 12, Provider]
“The navigators go to the patients’ houses to see if they have anything in their house – like if they would need a refrigerator. They can go over there and look at their food, they can go over their food, what kind of living [arrangements], what kind of housing. They can help with a patient that is having trouble reading, trouble with transportation, trouble with food, trouble with electric. If they just need more information on nutrition and they don’t have the transportation to get here, the diabetes navigators can go to their home to help them there, or just meet them someplace.” [ID 3, Office Staff]
“A navigator who is trained in healthcare of some sort goes and identifies needs of diabetes patients, whether it be financial or transportation, food acquisition. Some way to improve their care in a way that we aren’t able to in the clinic.” [ID 17, Provider]
Early successes
Theme 2: The navigators are the eyes in the community and the patients’ homes
“I can tell you about one patient…she was referred because her blood sugars were out of control…I met her at the clinic she had bruising all over one side of her face and of course the first thing I did was ask her about the bruising. She was being abused by the brother that she was living with at the time. So number one thing was to get her out of that situation, but in doing that I discovered… I took her out to lunch while we were waiting to get her into a shelter and found out that she was not able to add together, the sliding scale together with the other dose. Plus, her eyesight was so poor she could not read what she was drawing up…So we were able to discover things that the clinics can’t or don’t have time to do.” [ID 10, Navigator]
“We depend very much on this outreach and many times it’s important to understand the patients’ circumstances so I view them as our eyes in the community and the patient’s home because it helps us understand obstacles that people face and that they don’t necessarily share during the medical interview and the history.” [ID 2, Provider]
“I think the Diabetes Navigators can be really helpful in bringing the rest of that person into the room with the physician, that this person is not just diabetes with this A1C level, but this is a person who is also a caregiver and has these challenges and is going back to school, or doesn’t have sufficient access to healthy food, or needs additional transportation supports to make it to their appointments or what have you. So they can help personify and also overcome some of those barriers.” [ID 12, Provider]
“I’ve had a couple of patients that really benefitted because they were able to either get more food stamps or they realized they were eligible for Medicaid or they were able to get some resources they may not have had before, which has helped them in other ways because there are a lot of social pieces to diabetes management. And that has helped me in some ways provide better care for my patients.” [ID 17, Provider]
“I think sometimes what’s really needed with patients is just knowing that somebody is going to be following up on a frequent basis with them instead of once every three months for appointments. And just having a conversation or looking at their blood sugar logs I think is an amazing way to help people stay on track. And so the navigators have really helped with that. Even going to the homes too and finding out what the family situation is like, what the home environment is like and giving us a little bit of insight into challenges.” [ID 16, Provider]
“I’ve seen patients who’ve A1cs that have dropped because of the reminder or now that they can come to their appointments like they should, or they can now afford their medication that they couldn’t because of a program that maybe was related to them, or somebody just to remind them how important it is and why.” [ID 4, Office Staff]
Ongoing challenges
Theme 3: Difficulties with cross-system integration of services
“The thing that I find as a barrier for me with referring to navigation is I have to run off progress notes and not only fill out the form, but they want some documentation from the chart because the navigator doesn’t have access to it. And that’s ridiculous! And that is a barrier for me. Because I get busy and I don’t have time to go and run off whatever they need. It needs to be more streamlined and easy to make the referral.” [ID 16, Provider]
“They can be more specific in identifying their needs I think. It would be really nice because I remember getting a lot of referrals that were just a referral with nothing else written on it. I don’t know if we could make it easier by making our referral more specific so that all they would have to do that…If you don’t have a picture before you go in [navigation visit], it makes it twice as hard and twice as long to get that relationship established… It just makes it much more difficult. So I think that is a major thing. Making things really specific as to why they’re doing this referral.” [ID 10, Navigator]
“When we started doing this, there was no communication back. I would refer someone and not know if they had even touched base with a navigator or what they were doing with them. And it was frustrating… I want to know what issues are identified and I want to know what our plans are to help with those issues. And if it’s beyond what we can do for someone, then say it’s beyond what we can do for someone. So we can better utilize the program for people we know can be helped.” [ID 17, Provider]
“Making sure there is good communication between the navigator and the clinic so that the patient benefits the most from that in the sense that the entire healthcare team understands and knows all the different aspects of what is going on in their care. So it is important that the physician or the nurse practitioner understands and knows that these certain barriers have been taken care of because that might change how they address their care at their next appointment, whether things they choose to address or to congratulate the patient on and encourage them on. So I think communication, making sure that both ways is open and ongoing and documented appropriately.” [ID 14, Administrator]
“I believe the challenges related to communication and availability of the navigator stem from the expectation that we would perform as if we were clinic employees adhering to standardized forms, reporting formats, and agency culture. Because we serve patients from multiple counties, we need the flexibility to communicate in a way that provides information that we feel the provider needs to know and is not usually asked in the clinic setting; information often related to social determinants: living conditions, anything leading to the inability of the patient’s ability to adhere to the physician’s directions. Often the format that providers use and prefer allows only for the gathering of information typically expected and gathered in a clinic setting. It is likely that the autonomy needed to best provide information for and about our clients can be challenging for stringently standardized environments and our non-formatted information was sometimes refused and not always provided to the physician.” [ID 7, Navigator]
“I think the quicker the notes can be provided to the physician’s office to be updated in the EHR I think the better off it is. I think a major gap right now, is you have navigators who do not have access to the EHR, so they have to rely on what’s been faxed and a referral. So I see it as we have two separate models right now working.” [ID 1, Administrator]
“Being able to communicate verbally is really, really helpful. But notes would be great too. And if they did have access to the EHR, we could see their notes because it will be in the chart. But right now you have to look for scanned-in documents on the chart. And it’s less likely that you’re going to bump cross it.” [ID 16, Provider]
“I think that if they were in the office we could just [say], ‘Hey, do you have a minute to touch base with this person?’ It would be easier…I think we would get better communication that way. Because then they could even come tell me, ‘Hey, this is an issue with this patient I just found out about.’ If the navigator was in the office more, we would be able to talk more in real-time.” [ID 17, Provider]
“I think co-location and integration are important. I think they [navigators] need to be physically housed in the space so you can have those warm handoffs when you have someone who is in a situation…You can bring them in the room with you so that they can hear what is going on, they can be a part of the care team…where they’re meeting with the team regularly and having an opportunity for feedback and information back and forth.” [ID 13, Administrator]