Frequent ED visitors decreased their visits by 50% at New York-Presbyterian health system hospitals after community health workers, called patient navigators, began connecting at-risk patients to primary care providers and educating them on how to seek treatment at an appropriate level of care.

The patient navigator program was launched in 2008 and focuses on patients who are not connected to a patient-centered medical home and/or have no funding for healthcare. In the first seven years of the program, 92% of the patients who did not have a primary care provider and who worked with a patient navigator had an appointment with a new provider after discharge, and 77% of patients attended their follow-up appointments.

The patient navigators are employed by the health system and located in the ED. They are bilingual, live in the communities they serve, and understand the cultural beliefs and practices of the population. Their shared life experiences with ED patients enables them to build trust and provide peer-level support, says Patricia Peretz, MPH, lead for the Center for Community Health Navigation at New York-Presbyterian Hospital.

The patient navigator program is in five different EDs, Peretz says. The largest hospital, New York-Presbyterian/Columbia University Medical Center, has patient navigators on site 24 hours a day, seven days a week. Patient navigators at smaller hospitals typically staff the ED from 7 a.m. to 11 p.m.

The ED medical record software includes built-in decision support to help the treatment team identify patients who could benefit from an intervention by a patient navigator. In addition, if the provider team determines that the patient needs to find a medical home or may need support with keeping their follow-up appointments, they can make referrals, says Adriana Matiz, MD, associate professor of pediatrics at Columbia University Medical Center and medical director for the Center for Community Health Navigation at New York-Presbyterian.

Patients eligible for the program are frequent ED users, are not established with a primary care provider, and/or have no funding source, Peretz says.

The patient navigators meet with the ED patients and link them to financial assistance programs and other community resources. They help patients identify a primary care provider in a convenient location, and schedule primary care and specialist appointments. They educate patients on why they shouldn’t use the ED for primary care, and teach them how to navigate the healthcare system.

After the patients are discharged from the ED, the patient navigators follow up with them by phone and stay in touch until the patients schedule and attend a primary care appointment. They call the patients before their appointments to remind them to go, and call them after the appointments to make sure they went.

“In the past, emergency department staff would help a patient set up a follow-up appointment, but the relationship ended when the patient was discharged. The patient navigators in our program follow patients until they successfully make it to their appointments,” Peretz says.