How Patient Navigators Improve Care and Lower Cost of Healthcare

Improving patient outcomes has always been a priority for physicians, but now, these outcomes are increasingly tied to payments. Payers want to ensure that they pay for care that provides value to patients and helps them live healthier lives. However, one challenge of value-based payment models is that patient outcomes aren’t necessarily based on care provided in a single setting. In reality, patients often move through multiple disparate settings, each of which plays a role in whether they ultimately achieve positive results. 

Without a guide on this somewhat rocky journey, some patients may not follow through with treatment or referrals. That’s where a patient navigator can help, says Patricia Alvarez Valverde, PhD, MPH, director of the Patient Navigator Training Collaborative (PNTC) at the Colorado School of Public Health in Aurora, Colorado.

“Our healthcare system is fragmented,” says Valverde. “When patients go from a primary care provider to a specialist or offsite location, there are a lot of opportunities for patients to fall through the cracks.” The core purpose of patient navigation is to reduce barriers to accessing or completing care, says Valverde. This includes social, emotional, physical, or logistical barriers that prevent patients from achieving positive health outcomes, she adds.

What Is a Patient Navigator?

Patient navigators identify the social determinants of health that might hinder individuals from moving forward with treatment, such as lack of insurance, unstable housing, mental health diagnoses, lack of transportation, or a whole host of other barriers. Navigators address these barriers by connecting patients to community resources and services and serving as a mentor to help patients stay on track, says Valverde. 

Patient navigators are well-versed in topics such as health insurance terminology, health literacy, motivational interviewing, and behavior change. Unlike care coordinators who tend to address programmatic requirements (e.g., reducing readmissions), patient navigators focus more broadly on health disparities across all populations and can therefore have a bigger potential impact on outcomes, she adds.

Who Can Serve as a Patient Navigator?

Patient navigators hail from a variety of professional backgrounds, says Valverde. For example, some navigators previously worked as nurses or social workers. Others are laypeople with a desire to help individuals navigate the healthcare system. All navigators must have strong interpersonal and problem-solving skills, be able to build rapport and trust, be well-connected to community resources, and understand how to render services within their scope of work, she adds.

When thinking about what type of individual to hire, practices should first identify the focus of the navigator program and what tasks that navigator will typically perform. That will dictate the qualifications a navigator must possess, says Valverde. For example, if the practice wants to focus on clinical coordination of care with specialists for patients who have diabetes, a nurse or social worker may be more qualified. If the need pertains more around addressing cultural barriers, cultural health beliefs, or historical mistrust, then a layperson who understands the population may be equally as qualified, she adds. Some practices even train their medical assistants or front-office staff members to perform some of the tasks associated patient navigation.

How to Integrate a Patient Navigator Into the Workflow

When it comes to patient navigators, there is no cookie-cutter approach, says Valverde. Some practices choose to perform a health assessment at check-in so a patient navigator can introduce him or herself before the patient meets with the physician. Others ask the navigator to meet with the patient after the appointment or call the patient later that day or the next day to ensure that the patient understood what transpired. 

“Patients don’t always understand the physician, and they may not get all of their questions answered, so it’s helpful for the navigator to follow up with the patient after the appointment,” says Valverde. 

Some practices also use navigators in between encounters as a check-in to make sure patients refilled their prescriptions, are taking medications correctly, and following through with additional treatment recommendations (e.g., additional tests, appointments with specialists, diet changes, or lifestyle changes), says Valverde. 

Regardless of the workflow, all practices should involve the patient navigator in team huddles and case conferences and clarify the role of the navigator within the practice, she adds.

Other Considerations

Practices may not realize that they can potentially bill for some of the tasks that patient navigators perform—even when the navigators are not nurses or social workers, says Valverde. Examples include counseling risk factor reduction (e.g., tobacco cessation) and behavior change intervention, chronic care management services, psychiatric collaborative care management services, transitional care management, advance care planning, and general behavioral health integration care management. 

However, many states require these individuals—who are also often referred to as community health workers—to be certified as a pre-requisite for billing. Nurses and social workers are already credentialed; however, laypeople may need to obtain specific credentials before practices can bill for their time or services. To learn more about state rules and requirements, visit the National Academy for State Health Policy website. 

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