Characteristics and Trajectory of Older Adults Supported by a Patient Navigator Program in a Hospital Setting: A Cohort Observational Study

To improve transitions in care, a new patient navigation (PN) program was introduced to support older adults with complex care needs transition from hospital to home. The patient navigator is a community social worker embedded in the hospital’s care teams. A cohort observational design was used to c...

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Bibliographic Details
Published in:Canadian journal on aging Vol. 44; no. 1; pp. 105 - 114
Main Authors: Liu, Grace, Kokorelias, Kristina M., Knoepfli, Amanda, Dasgupta, Tracey, Ziegler, Naomi, Guilcher, Sara J.T., Hitzig, Sander L.
Format: Journal Article
Language:English
Published: New York, USA Cambridge University Press 01.03.2025
Subjects:
Aged
Aged, 80 and over
Cohort Studies
Continuity of Patient Care - organization & administration
Female
Humans
Male
Middle Aged
Patient Discharge - statistics & numerical data
Patient Navigation - organization & administration
Patient Navigation - statistics & numerical data
patient navigation
transitions in care
les personnes âgées
données administratives
examen des dossiers
older adults
transitions dans les soins
aging
navigation des patients
administrative data
chart review
vieillissement
ISSN:0714-9808, 1710-1107, 1710-1107
Online Access:Get full text
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Summary:To improve transitions in care, a new patient navigation (PN) program was introduced to support older adults with complex care needs transition from hospital to home. The patient navigator is a community social worker embedded in the hospital’s care teams. A cohort observational design was used to conduct the study by analysing the patient navigator’s clinical notes and hospital’s administrative data to describe the characteristics of patients, scope of the patient navigator’s activities, and patient outcomes. Ninety patients were assigned to the patient navigator’s caseload (November 2019–November 2021) in which the average age was 78.9 (range 55–95). The most frequent PN intervention types were referrals to community services (66%, n = 59) and discharge planning (61%, n = 55). The patient navigator supported 66% patients (n = 59) in returning home and provided follow-up care for 74 days (average). This study provides important insights into the patient navigator’s role to guide decision makers in implementing PN programs for older adults in a hospital setting.
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ISSN:0714-9808
1710-1107
1710-1107
DOI:10.1017/S0714980824000321