St Joseph Regional Health Partners

Chi St. Joseph Health Regional created the navigation program to improve upon the prior unfunded pilot program in march of 2018. The plan created an ed navigation team to provide care coordination to the underserved eligible population (uninsured, medicaid, and medicare/medicaid patients), which would result in the reduction of both acute and chronic ambulatory care sensitive conditions encountered at our main emergency departments. The navigation program was created in effort to provide the community's underserved population with resources in order to decrease avoidable hospital system utilization by addressing social and Health barriers that prevented the patients from establishing with a medical home. The patient navigation team enrolls the eligible underserved patients based on the medical history, utilization history, assessed social barriers, and funding status. Once the patients are enrolled, they are provided with patient navigation services for 30 to 90 days. These services include direct access to a medical home, weekly touchpoint calls with the patient, and financial assistance based on the assessed barriers to healthcare. The financial assistance aids patients with primary care/urgent care visits, transportation, medication, dme, specialist visits, and dietary needs. The social navigators address social needs, while the clinical navigators address clinical needs to patients with chronic conditions. The social and clinical navigators collaborate with several Health and community providers such as healthcare specialty clinics, fqhc primary care clinics, case management, community programs, and ed staff to ensure proper navigation and education is provided to the patients and assist them in overcoming their barriers to healthcare. As the patients near the end of their enrollment period, they are educated and transitioned to the brazos valley Health resource center to provide future assistance. Our organization partnered with a local fqhc facility to provide primary care access for our patients resulting in a long term solution to manage patient care outside of the emergency department. The program went live june 15, 2018. The navigators have outreached over 5,789 times to the eligible population. Lastly, patients continue to be educated on proper healthcare system utilization and connected with their previous medical home or a new medical home for primary care. We continue to have monthly stakeholder meetings with the organizations executives, directors, and various department members to discuss and analyze current process, performance, and outcomes. Monthly review meetings still continue to occur to address any barriers or successes with the program. Monthly performance results are compiled and analyzed to determine the current performance achievement for the program, and determine if any adjustments need to be made.