Abstract
BACKGROUND: A novel Patient Navigator Program (PNP) was introduced at a Canadian hospital's Reactivation Care Centre (RCC) to support transitions by helping older adults navigate the complexities of delayed discharge stays by improving their transition from hospital to home. The PNP was comprised of a community agency patient navigator who was embedded into the RCC setting to support transitions in care, and who followed patients up to 90 days post-hospital discharge. The purpose of this study was to describe the PNP, which included detailing the needs of patients (i.e., socio-demographics, case-mix, delayed discharge), the scope of service provision (i.e., referral process, follow-up duration), and patient outcomes (i.e., post-discharge location). METHODS: A cohort observational design was used to collect data on the PNP mainly via the patient navigator's clinical tracking sheet, and secondly via the hospital's administrative system. Data analysis included the use of frequencies and descriptive statistics. RESULTS: Between November 2021 and October 2022, 100 patients were referred to the PNP, with 70 patients (39% male; 61% female; median age of 81 years) being admitted to the patient navigator's caseload. The patient navigator provided follow-up care for a median of 58 days, and supported 76% of the patients (n=53) to return to their next point of care (e.g., homes or to a supportive housing setting). CONCLUSION: The PNP led to a high proportion of patients being discharged back to the community. This study provides insights to providers and decision-makers interested in implementing PNP care models in a hospital in partnership with a community agency.