Patient Care

Community Impact

Future of Health

ED Navigators Expand Care Continuum for Vulnerable Patients

For Partners HealthCare’s most vulnerable patient populations, the emergency depart­ment (ED) is a frequent point of care for both medical and social health needs. These patients, many of whom are covered by the Partners HealthCare Choice Plan as part of the Medicaid Accountable Care Organization (ACO), tend to visit the ED at a higher rate than the general population – presenting an opportunity to meet these individuals at that point of engagement, connecting them with services and resources that support long-term health.

Launched in March 2018 as part of the Partners Medicaid ACO, the ED Navigator Program strengthens the link to primary care and reduces avoidable ED visits by providing appropriate supports and navigation services to address patients’ complex health needs. Situated in the ED, Navigators work one-on-one with adult and pediatric patients to con­nect them with their primary care provider, sharing information about care management programs as well as community resources for follow-up and support after their ED visits.

ED Navigators are currently in place at Brigham and Women’s Hospital, Massa­chusetts General Hospital, and North Shore Medical Center (NSMC) Salem Hospital, where they have conducted 2,284 initial patient encounters and have made 2,783 referrals for patients and families to a wide range of health care professionals, supports, and services as of February 2019.

By nature, EDs are fast-paced and often frenzied environments, which can be daunting for patients. ED Navigators offer a listening ear and a link to helpful resources. “Building relationships with patients allows me to engage them 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.

The new ED Navigator program draws on the best practices cultivated through other patient-support programs instituted over the past several years across Partners, including at NSMC. For example, NSMC Navigator Yovanny Fana has worked for over 10 years connecting vulnerable patients outside of the Partners Medicaid ACO with chronic care management, connections to social services, and bilingual communication. This is knowledge she’s shared as a mentor to Hannah, supporting quality care in a fast-moving environment.

“We knew we could better address our patients’ social determinant gaps and create a support structure through our encounters with them in the ED,” says Amy Flaster, MD, Associate Medical Director, Partners Population Health. “We focused on leveraging that moment to connect them with the right resources across our system. Patients want to live their healthiest lives; the ED Navigator program connects these patients to the primary care resources and social services to bring these goals to fruition.”

Header image: Hannah Godfrey, North Shore Medical Center