One of the missions of the Partners HealthCare Medicaid Accountable Care Organization (ACO), launched officially in March of this year, is to meet patients “where they are” with services that enhance their access to quality care. A new program is helping to do so by meeting patients seen in the emergency department (ED) and connecting them to appropriate services and supports.

Launched in April 2018, the Partners ED Navigator program was created to help better manage and support Medicaid patients in the ED. Some of these engagements are with patients who are seen in the ED regularly for both routine medical care and unmet social needs, which can range from food insecurity to domestic violence to substance use issues. Many of the patients engaged by this new ED Navigator program tend to visit the ED at a higher rate than the general population.

“These patients have been disenfranchised for a number of possible reasons—issues like housing instability may be negatively impacting their health, they might not be able to afford medications, or they might be struggling to get transportation to appointments so they have lower engagement rates with our primary care providers,” says Dr. Amy Flaster, the clinical director of the program, a Brigham and Women’s Hospital (BWH) Primary Care Physician and an Assistant Medical Director at Partners’ Center for Population Health.

Alex Sheff, Senior Program Manager, Medicaid Strategies at the Center for Population Health, explained: “We knew we could better address our patients’ social determinant gaps and create a support structure through our encounters with them in the ED. We focused on leveraging that moment to connect them with the right resources across our system.”

The program has trained three navigators at BWH, Massachusetts General Hospital (MGH), and North Shore Medical Center (NSMC), all fully dedicated to engaging in an in-depth visit with Medicaid patients in the ED in a way that the fast-paced nature of emergent care typically does not allow. They act as conduits between these patients and health resources in three key ways:

• By connecting them with existing or new primary care relationships and resources for enhanced long-term health management;

• By connecting them with other population health management programs, such as recovery coaches for substance use disorders and high-risk management programs for chronic disease; and

• By directly connecting them with community resources to reduce the burden of unmet social needs affect their health.

“Building relationships with patients allows me to engage patients back to primary care while also connecting them to resources in the community, social workers at the primary care offices, and Community Resource Specialists,” says Hannah Godfrey, ED Navigator at NSMC. “I experience gratitude from patients, especially when they are unable to get to appointments due to lack of transportation.”

“The moment I engage with patients is an opportunity to rebuild their lost trust in the medical care system and build empowerment within themselves to continue voicing their needs in the appropriate directions,” notes Mimi Velazquez, ED Navigator at BWH. “This role allows patients to feel someone is listening beyond the time constraints of other ED provider roles, that someone is attentive to their psycho-social needs—which are often tantamount to their immediate physical issues.”

To date, the ED Navigators program has had 514 unique patient encounters, with 529 referrals made for these patients to a wide range of services. Though plans are underway to expand the program and conduct clinical evaluations of its efficacy, its essential goal—to help patients connect to the resources they need to live their healthiest lives outside of the emergency room—will remain constant.

“Our patients express immense gratitude when their stories and deep-rooted issues are heard with a narrative ear and not a clinical one,” says Vanessa Adjei, ED Navigator at MGH. “Providing support and simply ‘being there’ for patients is what makes me successful in navigating patients to access and receive the appropriate care and resources that they deserve.”

Photo: Mimi Velazquez, ED Navigator, Brigham and Women's Hospital

Topics: Clinical Training, Health Professions, Access to Care, Medicare/Medicaid

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