The patient-centered medical home (PCMH) is widely advocated as a way to help reform the U.S. healthcare system into one that is more accessible, effective, safer and economical. Central to the PCMH concept is care that is “coordinated or integrated across all elements of the complex healthcare system and the patient’s community.” This is crucial since fragmented care leads to unnecessary services, duplication of information gathering and testing, and poorer health outcomes. Currently, time, personnel, and reimbursement constraints limit efforts by primary care practice organizations to provide coordinated care. Recognizing that New Jersey has one of the most fragmented healthcare environments in the country, Overlook Hospital Foundation funded a pilot project aimed at demonstrating how a patient navigator — someone who provides education and emotional support to patients and helps guide them through the healthcare system — can help improve care coordination for patients of primary care practices. The funding supported a patient navigator, shared by 4 community-based primary care physicians, to coordinate care for patients, help them obtain needed resources, and facilitate communication between the patient, primary care office, and specialist offices. With support from the Overlook Foundation and the UMDNJ Team Science Initiative grant, we evaluated this project by documenting the types of services the navigator provided, determining the barriers and facilitators to patient navigation in primary care practices, and understanding patients’, physicians’ and the navigator’s perspectives and experiences with this service.
The concept of the PCMH is supported by all the primary care specialty organizations and includes these principles: 1) an ongoing relationship with a personal physician for first contact, continuous and comprehensive care; 2) a physician-directed team that collectively cares for the patient; 3) whole-person orientation including acute, chronic, preventive and end-of-life care; 4) coordinated care across all elements of the healthcare system and the patient’s community; 5) quality and safety achieved through evidence-based medicine, clinical decision-support tools, information technology, registries and continuous quality improvement; 6) enhanced access through systems such as open scheduling, expanded hours and new options for communication between patients, their physician and practice staff; and 7) payment reform to reflect the added value that a PCMH provides to patients.
Most PCMH demonstration and pilot projects focus on information technology capabilities, yet much of what is needed to foster a medical home for patients involves highly personal and individualized interaction with physicians to assist patients in obtaining the needed resources and care at the right time. While physicians have the capacity to provide ongoing patient-centered care, helping patients gain access to needed services can be complicated in the current primary care business environment. Robert Eidus, MD, MBA, a solo physician at Cranford Family Practice, received a grant from Overlook Hospital Foundation for a 12-month pilot project using a patient navigator (PN) to provide care coordination as well as education and emotional support to patients while guiding them through the healthcare system.
A social worker was hired to act as the PN and her services were shared by 4 physicians in 4 different primary care (internal medicine and family medicine) practices. Although 3 of the 4 physicians were in group practices, the pilot was limited to one physician per practice so that the navigator could develop a good working relationship with each physician. Physicians referred patients whom they felt needed extra coordinating services to the navigator. Patient selection was purposefully not restricted by a disease process to be consistent with how patients with multiple chronic conditions are cared for in primary care practices.
Building on our research team’s expertise in patient navigation, organizational change, and practice improvement, we conducted a mixed methods evaluation of this pilot project. Data analyzed included patient surveys, navigator tracking tools and biweekly debriefings, email communications from Dr. Eidus, project meeting notes, and in-depth interviews of 15 patients or family members and the 4 physicians (at the beginning and end of the project).
Navigator activities: The PN provided services to 75 mostly elderly patients with varied health conditions. The bulk of the PN’s activities focused on arranging social services and locating ancillary resources. Other activities included assessing patients’ needs, providing emotional support to patients and family members, coordinating complex referrals, and enhancing communication between physicians and patients. Most activities were conducted by telephone, although the PN met in person with 7 patients.
Integration with practices: The PN communicated directly with physicians and often had no communications with other practice members. Aspects of the research design (patient selection from patient list rather than at point of care, collection of survey data from patients before PN contact) affected flow of referrals. Lack of dedicated office space hindered integration of the PN within practices. However, both the PN and physicians, in the context of this study, did not report a need for greater integration to meet patient needs.
Patients’ and physicians’ perspectives: Many patients reported the PN relieved their own or their family members’ burdens. Most physicians saw the PN as providing a new service for patients rather than helping meet existing practice demands. Although patients and physicians found this service helpful, neither group expressed a willingness to pay for it.
Patient navigation services are useful for patients who need emotional support and coordination of social services and complex referrals. These services are typically not provided in community-based primary care practices. Payment reform, one of the key principles of the PCMH, will be needed to make the PN financially feasible in primary care. This pilot project laid the foundation for the submission of an application (PI: Ferrante) to the Agency for Healthcare Research and Quality entitled “Increasing Preventive Services in Medical Homes Using Patient Navigation,” that is currently pending review. In this project we will demonstrate the cost-effectiveness of patient navigation for delivering the patient-centered, team-based, coordinated care principles of the PCMH in community primary care practices, and provide validation for third party payment and dissemination of the patient navigator role into primary care sites.
Jeanne Ferrante, MD, MPH, is associate professor of family medicine at UMDNJ-Robert Wood Johnson Medical School (RWJMS). She is a family physician and health services researcher with expertise in primary care research and patient navigation. She is a recipient of an NCI career development award focusing on obesity and cancer screening.
Deborah Cohen, PhD, is assistant professor of family medicine at RWJMS and associate editor for the Annals of Family Medicine. She examines the role of clinician-patient communication and practice organization in healthcare quality. She has developed methods for evaluating translation research in primary care.
Jesse C. Crosson, PhD, is assistant professor in family medicine at RWJMS and director of the New Jersey Family Medicine Research Network. His research is focused on the use of health information technologies and improving the quality of chronic illness care in primary care settings.