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Navigating to Health

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Reaching Patients with Chronic Illnesses

What will help to bring patients who have not seen their primary care physician back for a visit?
Some high-risk patients at the Edward M. Kennedy Community Health Center with type 2 diabetes and/or hypertension were not regularly seeing their primary care physician for care. The health center wanted to develop a way to reach out
to these patients to help bring them back in to the health center for care.

This challenge developed into a shared applied UMass Chan PRC research project from 2009-2014, led by Dr. Milagros Rosal of the UMass Chan PRC, and Leah Gallivan, Dr.Jose Ramirez, and Brenda Figueroa of the Edward M. Kennedy Community Health Center. The team created a Patient Navigator program aimed to re-engage patients with type 2
diabetes and/or hypertension that had not been seen by a Primary Care Physician in the previous six months. Bilingual, bicultural Patient Navigators contacted patients by phone to build rapport, discuss the importance of follow up care, identify challenges to attending appointments, and assist in overcoming these challenges. After patients were connected to the
Primary Care Physician or Chronic Disease Nurse and attended their visits, Patient Navigators worked with the medical team to schedule other necessary visits.

The study found that Patient Navigators may be effective in re-engaging patients with diabetes and/or hypertension with primary medical care when they are able to speak with patients directly. This personal attention may help to strengthen a patient’s motivations to take care of himself or herself, and is more effective in bringing them back to the health center than simply receiving messages left via voicemail or with a family member.

As Patient Navigators were bilingual and bicultural community members, these characteristics are presumed to foster rapport with patients in a manner salient to patients. Findings from this study may guide future processes and decisions regarding the integration of Patient Navigators within medical teams and population-based medicine guidelines to effectively manage community and population health.

Read the Research Brief to learn more!