Southside Pain Patient Pre Appointment Online Questionnaire

Southside Pain Patient Pre Appointment Online Questionnaire

  • Journal List
  • Westward J Emerg Med
  • v.22(2); 2021 Mar
  • PMC7972383

W J Emerg Med.
2021 Mar; 22(2): 417–426.

“I wanted to participate in my own care”: Evaluation of a Patient Navigation Program

Elizabeth A. Samuels, Physician, MPH, MHS,

Lauren Kelley, MSW, MPA,
Timothy Pham, MPH,
Jeremiah Cantankerous, MD,
Juan Carmona, MS,
Peter Ellis, MD, MPH,
Darcey Cobbs-Lomax, MBA, MPH,
Gail D’Onofrio, MD, MS,
and Roberta Capp, MD, MHS||

Elizabeth A. Samuels

*Warren Alpert Medical Schoolhouse of Brown University, Department of Emergency Medicine, Providence, Rhode Isle

Lauren Kelley

Project Access-New Haven, New Oasis, Connecticut

Timothy Pham

Project Admission-New Haven, New Oasis, Connecticut

Jeremiah Cross

Highland Full general Infirmary, Department of Emergency Medicine, Oakland, California

Juan Carmona

Project Access-New Haven, New Haven, Connecticut

§Yale University School of Medicine, Section of Medicine, New Haven, Connecticut

Peter Ellis

Projection Admission-New Haven, New Oasis, Connecticut

§Yale Academy School of Medicine, Department of Medicine, New Oasis, Connecticut

Darcey Cobbs-Lomax

Projection Admission-New Haven, New Haven, Connecticut

Gail D’Onofrio

Yale Academy Schoolhouse of Medicine, Department of Emergency Medicine, New Haven, Connecticut

Roberta Capp

||Academy of Colorado Schoolhouse of Medicine, Department of Emergency Medicine, Aurora, Colorado

Received 2020 May 8; Revised 2020 Sep viii; Accustomed 2020 Sep 21.

Supplementary Materials

GUID: 604852FD-C122-4B8B-9CEA-E9528BE7A8E9

GUID: 12CF4D98-0095-4761-BD21-09FED876533D

GUID: AA1AD3DE-8CEB-4590-BAE5-25CA813BCA32



Patient navigation programs can help people overcome barriers to outpatient intendance. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for Us Medicaid-enrolled frequent ED users.


We conducted a mixed-methods evaluation of patient experiences and satisfaction with an ED-PN program for patients who visited the ED more than four times in the prior year. Participants were Medicaid-enrolled, English- or Spanish-speaking, New Oasis-CT residents over the age of eighteen. Pre-mail service ED-PN intervention surveys and post-ED-PN individual interviews were conducted. We analyzed baseline and follow-up survey responses as proportions of full responses. Interviews were coded by multiple readers, and interview themes were identified by consensus.


A total of 49 participants received ED-PN. Of those, 80% (39/49) completed the post-intervention survey. After receiving ED-PN, participants reported high satisfaction, fewer barriers to medical care, and increased confidence in their ability to coordinate and manage their medical care. Interviews were conducted until thematic saturation was reached. Iv main themes emerged from 11 interviews: 1) PNs were perceived as effective navigators and advocates; 2) health-related social needs were frequent drivers of and barriers to healthcare; 3) chief care utilization depended on dispensary accessibility and quality of relationships with providers and staff; and four) the ED was viewed as providing convenient, comprehensive intendance for urgent needs.


Medicaid-enrolled frequent ED users receiving ED-PN had high satisfaction and reported improved power to manage their wellness conditions.


Us emergency department (ED) utilization has increased over the terminal three decades at a charge per unit faster than the US population has grown.1
Frequent ED users, divers as individuals with four or more ED visits in a one-year period, incorporate 4.5–viii% of all ED patients, yet account for 21–28% of all annual ED visits.iii
Frequent ED users are more than likely to exist older, take chronic illnesses, be Medicaid-insured, and have complex medical, behavioral wellness, and psychosocial needs.3

Approximately 85% of ED visits amid Medicaid-enrolled frequent ED users result in belch home. Many of these visits could occur in a chief care setting, which is more than cost-effective and improve for long-term patient outcomes.8

However, Medicaid patients have greater difficulty scheduling outpatient appointments compared to privately insured patientsxi
and encounter many barriers to accessing primary intendance, including lack of transportation and appointment availability.6


Patient navigation programs have been implemented beyond the US to help patients overcome barriers to accessing outpatient care.fifteen

These programs provide services navigation, education, and care coordination.8
Many patient navigation programs have demonstrated success in reducing ED utilization and healthcare spending,15

but few have examined patient acceptability, experiences, and satisfaction. Evaluating patient experiences is critical for understanding which aspects of these programs successfully appoint and run across patients’ needs. In this mixed-methods study, we evaluated patient perspectives, experiences, and satisfaction with an ED-initiated patient navigation (ED-PN) intervention for Medicaid-enrolled frequent ED users.24


Study Setting and Population

We recruited participants from the Yale New Haven Hospital (YNHH) ED, a large, urban, academic hospital in New Oasis, CT, treating over 100,000 adult patients annually. New Haven has over 130,000 residents (33% Black, 32% White, and 27% Hispanic). Of this population, 48% live at or beneath 200% of the federal poverty level.25
Twelve pct of Medicaid-enrolled YNHH ED patients are frequent ED users, accounting for 38% of all ED visits.26

Participant Recruitment and Enrollment

Individuals were eligible for inclusion if they had the following characteristics: 18–62 years sometime; Medicaid-enrolled; English or Spanish speaking; residents of one of the twelve towns in the greater New Haven expanse; had 4–xviii visits to a YNHH ED in the prior year; less than 50% of their prior year ED visits were for a psychiatric or substance use business concern; and they were not being primarily treated for a psychiatric or substance employ concern at the time of enrollment. We excluded from enrollment patients with frequent ED utilization for substance use disorders and behavioral health problems because they take additional and ofttimes circuitous clinical, behavioral, and social needs that the intervention was non designed or equipped to support.24

Participants were enrolled from March 2013–February 2014. Afterwards providing informed consent, they were randomized to either ED-PN or standard care using a previously generated, stratified randomization algorithm with a curtained sequence. Of the 100 individuals enrolled, 49 received the ED-PN intervention and 51 received standard care. The PNs were employed by Project Access-New Haven (PA-NH), a customs-based non-profit that provides patient navigation to medical specialty services for people who are uninsured and Medicaid-enrolled.27
Details most study enrollment and randomization can be found in previously published manuscripts.half-dozen

Population Wellness Research Capsule

What practice nosotros already know about this issue?

Patient navigation (PN) programs provide services navigation, education, and care coordination, resulting in reduced ED apply, hospitalizations, and healthcare costs.

What was the research question?

What are patient perspectives, experiences, and satisfaction with an ED-initiated PN program?

What was the major finding of the study?

Participants were highly satisfied with ED-initiated PN and reported increased self-confidence managing their health.

How does this amend population health?

EDs can use patient navigation programs to support and improve the health of marginalized and medically circuitous patients.

Patient Navigation Intervention

Participants in the intervention arm received ED-PN for 12 months through PA-NH, a customs-based nonprofit organisation providing PN services for underserved Greater New Haven area residents.27
The navigation team included a bilingual (English/Castilian) patient nagivator and a nurse navigator. Both completed a two-day intensive training at the Harold Freeman Establish for Patient Navigation on how to provide PN and address barriers to care.28
Study navigators had supervision from a multidisciplinary team comprised of an emergency physician, a primary care dr., the PA-NH executive director, and a program coordinator. The study team met weekly, developed tailored plans for each participant, and provided direction on coordination of medical and social services.

The navigators scheduled mail-ED chief care visits for each participant and offered accompaniment to upwards to three part visits. They met the participants prior to outpatient appointments to review their concerns and outline questions for the provider. Navigators encouraged participants to ask questions during the visit and helped create a post-visit job list based on the provider’south recommendations. The patient navigators also scheduled visits for provider-recommended specialty care and ancillary services.

Navigators contacted participants by phone every two weeks during weeks 0–4 and every four weeks during weeks xiii–52 to review participants’ health and social needs. They also scheduled and reminded patients of medical appointments, addressed barriers to care, and provided referrals for social needs. Finally, navigators were available to answer participant questions and provide assistance every bit needed.

Report Blueprint

Participants completed a baseline questionnaire (via staff interview) at enrollment that included questions about demographics, health status/needs, healthcare utilization, and admission/barriers to care. I-yr post-enrollment and following completion of the ED-PN intervention, a research assistant not directly involved in PN conducted follow-upwards phone surveys to assess participant-reported healthcare utilization, access/barriers to care, and program satisfaction. Follow-up survey completion had no bearing on receipt of ED-PN. Survey questions included novel and validated questions to measure health literacy,29
healthcare utilization,31
health condition,32
and cocky-efficacy for managing chronic diseases33
(Appendix A). Surveys were piloted with patient navigators for comprehension and lasted approximately 15–30 minutes. Responses were collected using a web-based platform (Qualtrics XM, Provo, UT). Respondents received a $25 souvenir card for participation.

Upon completion of the follow-up survey, English language-speaking ED-PN participants were invited to participate in a qualitative interview virtually the PN program. The study team developed the interview guide, which was reviewed past patient navigators for understandability and iteratively revised (Appendix B). The interviewer had not previously interacted with whatever of the participants. Audiorecorded interviews were approximately 45–60 minutes in length and transcribed verbatim. Interviews were conducted until thematic saturation was reached. Participants received a $50 gift card for completing the interview. Interview and follow-up survey completion occurred following completion of ED-PN intervention. Participants were informed that participation in these assessments had no bearing on current or futurity services received. This study was approved by the Yale University Institutional Review Board.

Read:   Family Medicine Mt Pleasant Iowa Patient Portal


Patient Surveys

We analyzed baseline and follow-upward survey responses as proportions of full responses. The datasets analysed are available from the respective writer on reasonable request.

Patient Interview

The coding structure and categories followed the topical framework of the interview guide and were iteratively refined through group discussion. The coding nomenclature scheme was finalized by consensus and applied to each transcript by at least two contained reviewers. Whatsoever coding discrepancies or ambiguities were resolved through word. Codes were applied to each transcript using ATLAS.ti version 5.2 (ATLAS.ti, Berlin, Germany). The report team reached consensus on a concluding thematic framework and identified illustrative quotes that represented the responses relevant to each theme.


Survey Results

Forty-nine participants received ED-PN. Over half were female (67%), near half (47%) were Black, most spoke English (86%), and over one-half (57%) worked at least part time (Table one). Over half (65%) reported off-white to poor health at baseline and most (86%) had at to the lowest degree ane chronic wellness condition. At baseline, 48% reported not being able to go outpatient appointments every bit before long every bit needed and 70% reported receiving most of their healthcare in the ED (Table 2). Of the ED-PN participants, 80% (39/49) completed the mail ED-PN survey (Table 3). After receiving ED-PN, participants were more likely to report “unremarkably” or “always” getting medical appointments as before long as needed (94% vs 53%) and having their medical questions answered the same day (96% vs 50%). Participants also reported decreased use of the ED as their primary site of intendance (xxx% vs.70%), fewer barriers to intendance, and increased confidence in their ability to coordinate their own care and cocky-manage their medical conditions (Tabular array 3).

Table 1

Demographics of all participants receiving emergency department patient navigation and individuals interviewed.

All navigation recipients (n=49) N(%) Interviewees (north=11) N(%)
 Female 33 (67) 9 (82)
Age (mean years) forty.2 37.1
 Hispanic/Latino 19 (39) iii (27)
 Not-Hispanic, Black 23 (47) 6 (55)
 Non-Hispanic, White 5 (ten) 1 (9)
 Non-Hispanic, American Indian/Alaska Native ane (2) ane (9)
 Not-Hispanic, Other one (2) 0 (0)
Primary language
 English 42 (86) 10 (91)
 Spanish vii (14) 1 (nine)
Marital condition
 Never married 21 (43) v (45)
 Married/ceremonious union/living with partner 12 (24) 2 (18)
 Separated/divorced/widowed 16 (33) 4 (36)
 Elementary/grade school 5 (x) 0 (0)
 Some high school vi (12) 1 (9)
 High school/GED 18 (37) v (45)
 Some college (no degree) 14 (29) 4 (36)
 Associate’due south/Available’due south Degree six (12) i (9)

Tabular array ii

Social, economic, and health characteristics of participants receiving emergency department patient navigation and individuals interviewed.

All navigation recipients (north=49) N (%) Interviewees (n=eleven) N (%)
Food insecurity (not plenty food/money to purchase food in past 30 days)
 Never 21 (43) 4 (36)
 Sometimes 21 (43) 6 (55)
 Often seven (xiv) 1 (ix)
Housing instability
 Did non spend last 7 days in own place 10 (20) three (27)
 Homeless in past twelvemonth (≥1×) vi (12) 1 (nine)
Health literacy
 Mean REALM score (scale: 0–7) 5.0 five.2
 Depression health literacy (REALM score <=six), N(%) 33 (67) 6 (55)
Health status (self-report)
 Poor 11 (22) 3 (27)
 Fair 21 (43) v (45)
 Good ix (xviii) 2 (18)
 Very good iv (8) 0 (0)
 Excellent 4 (8) 1 (9)
Healthy days measure (mean days)
 Poor physical or mental health (N days in last xxx days) 21.0 19.2
 Unable to exercise usual daily activities (Due north days in terminal days) eleven.5 thirteen.2
Chronic conditions (self-reported)
 Hypertension 21 (43) 4 (36)
 High cholesterol 11 (22) 2 (xviii)
 Coronary heart disease three (6) 1 (ix)
 Congestive heart failure 3 (6) ane (9)
 Centre attack 2 (four) 1 (ix)
 Asthma 22 (45) 4 (36)
 Diabetes fourteen (29) 2 (18)
 Chronic lung disease/COPD 2 (4) 1 (9)
 Depression 27 (55) five (45)
 Anxiety 22 (45) 5 (45)
 Other mental disease 5 (x) 2 (xviii)
 Cancer 3 (6) 0 (0)
 Stroke 2 (4) 1 (nine)
 At least 1 of the above chronic conditions 42 (86) viii (73)

Table three

Participant-reported ability to become appointments and answers to medical questions, barriers to care, and ability to coordinate and manage their medical conditions before and after receiving emergency department patient navigation.

All Navigation Recipients (n=49) Interviewees*

PRE (n=49)
N (%)
Post (north=39)
North (%)
PRE (n=11)
N (%)
Postal service (north=9)
North (%)
Appointments as shortly as needed (by 12 months)
 Never 10 (24) i (iii) 5 (45) 0 (0)
 Sometimes 10 (24) 1 (3) ii (eighteen) 0 (0)
 Usually 7 (17) four (11) 0 (0) ane (11)
 Always 15 (36) 30 (83) iv (36) 8 (89)
Medical questions answered same day, regular business organisation hours (by 12 months)
 Never ix (26) 0 (0) 3 (30) 0 (0)
 Sometimes 8 (24) i (4) iii (30) 0 (0)
 Usually 5 (15) iii (13) 1 (10) 0 (0)
 Always 12 (35) nineteen (83) 3 (30) 8 (100)
Barriers to care
 Cost 20 (41) 5 (13) 1 (9) 1 (11)
 Transportation 32 (65) 16 (41) nine (82) 5 (56)
 Work schedule 12 (24) 6 (15) 2 (18) 3 (33)
 Childcare 9 (18) 4 (x) 2 (18) i (11)
 Unsure where/how to get intendance twenty (41) 3 (8) 4 (36) one (11)
 Hard to observe Medicaid providers xviii (37) 8 (21) 6 (55) three (33)
 Difficulty getting appointments soon enough 28 (57) 10 (26) 5 (45) 2 (22)
 Difficulty communicating with providers 6 (12) one (3) 2 (18) one (11)
 Difficulty agreement medical infor-mation 17 (35) two (5) iv (36) 1 (11)
 Difficulty filling prescription medications ten (20) iii (8) 2 (eighteen) 1 (eleven)
 Unhappy with past experience with provider 17 (35) vii (18) five (45) 2 (22)
 Prefer to care for self 12 (24) 0 (0) i (9) 0 (0)
 Disability viii (16) i (3) 2 (18) 1 (xi)
 None three (6) ten (26) 0 (0) 1 (xi)
Prepared to coordinate own intendance
 Non at all prepared 10 (20) 2 (five) iii (27) 2 (22)
 Mostly not prepared 5 (10) 5 (13) 2 (xviii) 0 (0)
 Somewhat prepared 19 (39) sixteen (41) 4 (36) 6 (67)
 Very prepared 15 (31) 16 (41) ii (18) ane (11)
Confidence in Cocky-Management of Medical Condition(s) (ane=Not at all confident – 10 = Totally confident)
 Mean half dozen.61 vii.74 vi.00 vi.78

Participants reported high overall satisfaction and identified assistance with scheduling appointments, engagement reminders, follow-up calls, and having someone to talk to almost their health as the about helpful navigation services (Figure, Panels A and B). Participant reported satisfaction with ED-PN services was high. All participants reported being overall satisfied with ED-PN, and 89.vii% (35/39) reported being very satisfied. The majority (87.two%, 34/39) also reported being very satisfied with how long they had to wait for a medical engagement. Most (87.2%, 34/39) reported that information technology was piece of cake to follow handling advice after getting ED-PN and easy to get intendance (76.9%, thirty/39). Subsequently receiving ED-PN, most thought their ability to get care had improved (84.half-dozen%, 33/39).

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Helpfulness of Navigation Components. Participant reported helpfulness of patient navigation services including assist with appointment scheduling and reminder calls (Console A), health organization navigation (Panel B), and health-related social needs (Console C). Responses are reported equally proportions of total responses in categories of NA, Non helpful at all, Slightly Helpful, Somewhat Helpful, Very Helpful, and Extremely Helpful.

PN, Patient navigator.

Interview Results

We conducted 11 interviews. Compared to the ED-PN group, most interviewed participants (due north = xi) were female (82% vs 67%) and Black (55% vs 47%) and fewer had full-time employment (9% vs eighteen%). Interviewees were otherwise similar to the overall ED-PN group in their sociodemographic characteristics and reported health (Tables 1

2). Iv main themes emerged: i) Patient nagivators were perceived as effective healthcare coordinators and advocates who provided continuity and individualized support (Theme 1); 2) health-related social needs were frequent drivers of and barriers to healthcare utilization that required PN assistance (Theme ii); three) main care utilization depended on dispensary accessibility and quality of interpersonal relationships with providers and staff (Theme 3); and four) participants characterized the ED equally providing user-friendly, comprehensive intendance for urgent needs and filling gaps in chief intendance access (Theme 4)(run across Supplemental Tabular array).

Theme 1: Patient navigators perceived equally effective healthcare coordinators and patient advocates who provided continuity and individualized back up.

Participants provided unanimously positive feedback about PN support. Many described feeling relieved about finally receiving the assistance they felt they needed. One participant observed, “You feel like nobody elsewhere is helping you and they’re at that place to help… I was at my wit’s end when [the PN] came to me. I was and then fed upward.” (Participant five)

Strong PN-patient relationships were consistently cited as a central program component. One participant described their relationship with the patient navigator as, “Wonderful… I felt that they cared, they actually cared, non just about me, simply actually me.” (Participant ten) Participants linked this directly to the development of self-worth and trust. PN services were viewed as non-judgmental, unconditional, and made participants feel comfortable. “They made me feel similar, ‘This is my paw extended out to you, whether you want it or yous don’t.’ They didn’t brand me feel bad, they made me experience comfortable.” (Participant 8)

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Patient navigators besides educated participants about healthcare utilization and what to expect from healthcare visits. Some participants said this allowed them to “[Know] my rights a picayune flake more.” (Participant 6) Drawing from PN education and support, participants described developing improved self-efficacy navigating the healthcare system. One participant reported feeling, “More than comfortable to go back to my principal care doctor and say ‘Hey, you lot’re my chief care dr., yous’re supposed to be the one to come across me and give me care’… I felt stronger… I felt empowered to make an appointment.” (Participant 6) The participant connected: “Within a year, I was able to…go to the primary care physician, go to the dentist. I was able to get going, I became familiar. I was driven, I … wanted to participate in my ain care.” (Participant vi)

Participants described developing very strong bonds and trust with their patient navigators and indicated that they made a noticeable difference in their lives. One participant described, “If it wasn’t for [the PN] I’thou telling you; I wouldn’t have been at none of these appointments. If information technology wasn’t for [the PN] checking on me, calling me, asking ‘did y’all do this, did you do that,’ I really was lost.” (Participant viii)

Theme 2: Navigators helped patients accost health-related social needs that were drivers and barriers to healthcare utilization.

Social, economic, and personal considerations were mutual factors that impacted participants’ healthcare utilization. Several participants commented that navigators helped them prioritize their health and healthcare appointments despite social barriers and competing concerns. One noted, “[The PNs] helped out because when I accept then many things on my listen, like … my daughter and her homework, or me trying to discover the, not the right job, simply the most beneficial employment… Is there food in the house, does she have the right shoes, this and that…So, for you to call me and remind me [to go to my appointments], that’s a cute thing.” (Participant iv)

Transportation, caregiver responsibilities, and housing were unremarkably cited barriers to accessing principal intendance. Patient navigators frequently assisted with transportation. One individual noted: “for bus passes you lot got to phone call seven days before and sometimes it’d come the day later on my appointment, but if I called [the PN], they’d go right on that phone, call transportation and they’d transport me a taxi that morning for my appointment.” (Participant 10)

A number of participants experienced major life events, such as incarceration of family unit members or family health problems, that impacted their wellness, further demonstrating that additional back up is be needed across the scope of the PN program. In such situations, navigators directed patients to local resources and provided emotional support. While most participants did non report receiving assistance with health-related social needs (Figure, Panel C), participants who did use these services reported positive experiences. However, the ED-PN intervention was not designed for comprehensive navigation to address these needs. During the form of the report, staff often noted feeling limited in their ability to address health-related social needs, particularly housing.

Theme three: Master intendance utilization was driven by clinic accessibility and quality of interpersonal relationships

Engagement availability, interactions with clinic providers and staff, and perceived intendance quality, thoroughness, and continuity were usually mentioned factors impacting main care utilization. Provider continuity and familiarity with one’south past medical history cultivated trust and condolement. Nevertheless, many participants who received care at the principal care resident clinic connected their decreased clinic utilization to their dissatisfaction with the dispensary stemming from lack of trust in providers, feeling rushed during appointments, and lack of conviction in the quality of clinic care.

The loftier volume of patients at the primary intendance dispensary and perceived lack of organisation were viewed as compromising patient intendance. Explained one participant, “With the main intendance clinic, is for one they are overpopulated. They’re non able to appraise each patient the way that they should…It’southward always hectic… when y’all walk into the clinic, yous can just experience the energy of people waiting for 2 and 3 hours to be seen by a medico. It’s no organization in the waiting room. It’s a mess. The dispensary is a mess.” (Participant 6)

Participants were also frustrated with lack of provider consistency at the primary care resident clinic. One participant explained, “You lot don’t want to continue seeing unlike people. You want to meet the same person…You’re always bounced effectually to different people where you lot’d have to explicate your whole story to because they don’t know yous. So, at that place goes your fifteen minutes right there.” (Participant 5)

Several patients commented that PN accessory to primary care provider visit(s) was benign and improved their overall experience of care. 1 noted: “[The PN] helped me realize you’re paying for this; yous have the right to enquire questions… and that helped me out a lot.” (Participant 8) Another participant described being treated differently when the PN attended her appointment: “They were all so squeamish, never happened earlier… I don’t know if they’re intimidated… considering she was a woman with a badge, dressed up nice, paperwork folders… I was treated perfect.” (Participant v)

Theme 4: Emergency department provides convenient, comprehensive care for urgent needs and fills gaps in principal care admission.

Virtually participants used the ED to fill up gaps in primary care and described the ED as a convenient identify to obtain comprehensive care for urgent needs. When weighing options for where to seek care, patients frequently viewed the ED every bit the only available pick for urgent needs. Said i participant, “I simply said, ‘Forget about [making an date].’ I couldn’t have the pain anymore. Then, I ended up in the emergency room.” (Participant ane)

Illness acuity in combination with other issues, especially limited transportation, also brought people to use the ED. Inability to get a timely date was oft mentioned equally a reason to use the ED. “When I tried to call the primary care centre, they weren’t bachelor the style I needed them to be available,” said one participant. She continued, “If I felt in that location was something important and medically urgent and to them it wasn’t, I wanted it that same 24-hour interval and they would exercise 3, iv days later and I felt to myself it was important, I would just go straight to the ED.” (Participant 5) Waiting to be seen in the ED was not viewed positively, only not necessarily a deterrent given perceived or actual disability to get timely master intendance appointments. Described one participant, “It’s normal to be a long wait [at the ED]. I don’t bash that. Sometimes it’s agitating only there are and so many people like me out there that can’t get aid at primary care doctors and physicians that they get then packed.” (Participant five)

After the program, several participants recognized the benefits of using principal care for comprehensive care and the ED for discrete problems. Ane participant described, “If you lot go to the main care it’due south like y’all’re having an appointment, they can check everything that you recall could possibly be wrong with you lot at this point in time. But when you become to the ER, you’re treated for whatever y’all came there for. Similar I broke my human foot, but I take a cough, they’re gonna treat your foot, but not the coughing.” (Participant 12)

Some participants reported continuing to use the ED after the ED-PN intervention when they were acutely ill, unable to go a chief care appointment, or due to hours of operation. A few participants noted that they preferred the convenience and perceived comprehensiveness of ED intendance. They besides acknowledged that being seen in the ED could also expedite access to outpatient care. One participant described, “And you lot know, [ED providers] will get things going… I know that in one case I get in the back, one time I tell them what is going on, they will practise a CT scan, they will do 10-rays, they will do all the emergencies that could be going on with me and refer me to my doc and so I’ll get an date to my primary care sooner.” (Participant six)


In this mixed methods evaluation, Medicaid-enrolled frequent ED users were highly satisfied with the ED-PN intervention and reported increased healthcare admission and self-confidence in managing their health conditions. Our findings underscore the value of navigation services to patients beyond traditional healthcare utilization and cost metrics. Participants in our study described many social factors that affected their ability to accomplish and maintain adequate health and access to main care including transportation, difficulty scheduling fourth dimension off from work, and problems with insurance. Given the importance and frequency of these factors in people’s lives and their touch on on healthcare utilization, future navigator programs need to prioritize addressing unmet social needs, aid that is non traditionally given in the healthcare arrangement. Participants noted that they needed boosted help with health-related social needs, and staff reported feeling limited in their power to address these issues. Further studies are needed to understand how best to assess and address health related social needs and to identify needs specific to different patient groups, especially people who do not speak English and were not included in written report interviews.

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Key factors driving decisions of where to seek healthcare included quality of relationships with primary intendance providers, engagement availability, and fourth dimension spent with providers. Participants reported a pregnant decrease in ED utilization, which is consistent with objective findings from prior plan evaluations that demonstrated reduced ED utilization and hospitalizations among people receiving PN and overall toll savings for participants who were older and had lower health literacy.24
Despite these changes, several participants felt they had ameliorate relationships with the ED, where their history was readily accessible in the electronic health record and they would spend several more hours at a fourth dimension interacting with caregivers, than with their main care offices.

There was an overwhelming perception that the ratio of time spent making and waiting for the appointment vs fourth dimension spent in the date was out of proportion. In the ED, on the other hand, despite long wait times, patients felt assured that they would receive a thorough workup. In addition, once in the ED, they were able to receive additional services without delay (eg, specialty consults, diagnostic tests) rather than making hereafter appointments that might require long await times for appointments, transportation challenges, time off from work, and childcare issues. These findings are consistent with previous studies that accept evaluated the impact of these factors, often referred to equally opportunity costs on healthcare utilization.34
The ED with 24/seven/365 day availability is a convenient site of care that people tin can access when these costs (time off work, childcare, transportation) tin exist minimized. This farther underscores the need for a patient-centered health system that lowers barriers to preventative and primary intendance by minimizing patients’ opportunity costs when accessing healthcare.17


This study has several limitations. Study participants were Medicaid-enrollees residing in and aroundNew Oasis, CT and may accept had specific needs non necessarily generalizable to different populations, rural areas, or smaller EDs. Yet, this study was designed for hypothesis generation regarding patient perspectives on PN programs. Interviewees varied slightly past gender, race, and employment condition compared to non-interviewees and may have had unlike degrees of unmet social needs compared to the larger intervention group. Due to the minor report sample and the fact that interview participation was optional, results may be subject to selection bias resulting in an increase in positive reported experiences with the PN plan. Additionally, nosotros did not interview those patients from the study command arm who primarily spoke Spanish, or those we could not attain past telephone after report completion; these participants may accept expressed different views. However, the types of barriers that interviews described, and the iv thematic domains that emerged are comparable to findings from similar research.14


This written report provides a deeper agreement of patient-oriented outcomes associated with patient navigation programs in addition to traditional metrics evaluated by other programs.17
Our findings advise boosted factors – the relationship between the navigator and clients, having a person in the healthcare organisation whom participants felt they could rely on and trust, and addressing health-related social needs – were highly valued by participants. This further supports the importance of tailoring navigation services to each private. While improved healthcare utilization and patient satisfaction are important outcomes, futurity investigations are needed to understand how to optimize navigation programs to provide sustained support over time and improve self-reported health and quality of life. Future cost analyses of patient navigation programs that take into account program cost and changes in hospitalizations and medical complications tin further appraise the value of these programs.

Supplementary Data


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Conflicts of Interest: By the
Due westJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or fiscal relationships with any companies that are relevant to this study. In that location are no conflicts of involvement or sources of funding to declare.


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