ED navigators steer patients with social, financial, or behavioral health needs to appropriate resources

Approach relies on effective working relationships between the navigators and ED staff

While studies show that most people come to the ED because of an urgent or emergent medical concern, some people wind up in an emergency setting because they are not plugged in to the kind of social or medical resources that could more appropriately meet their needs.

At Sutter General and Sutter Memorial Hospitals in Sacramento, CA, this problem became particularly acute at the height of the country's financial woes a few years ago. "People lost their jobs and lost their health insurance, and county clinics were closing," explains Holly Harper, the regional community benefits manager for Sutter Health's Sacramento Sierra region. "We have many programs that meet the needs of under-served populations, but what we were finding was that the ED was flooded with people who were in there for non-urgent reasons."

To address the problem, Sutter partnered with The Effort, the local federally qualified health center (FQHC), to establish ED navigators on-site in each of the hospitals' EDs between 1 p.m. and 10 p.m., seven days a week. The way it works is ED staff will alert the navigators to patients who arrive with no insurance coverage or primary care home, as well as patients who have mental health problems or significant social needs.

The navigators, who are employees of The Effort, will then meet with the patients while they are still in the ED to explore what types of health care connections these patients have, explains Rodney Kennedy, MFT, director of Behavioral Health Programs for The Effort. "A lot of these patients are either homeless or have mental health conditions, and they don't necessarily feel comfortable going to a regular health care provider," he explains. "So in working with them and engaging with them, we are able to assist in all those areas."

For example, for a patient who has no insurance coverage, the navigator will attempt to get him or her qualified for health care benefits and establish a follow-up appointment with a specific health care provider at one of The Effort's clinics. "We have five clinic sites in the Sacramento region," notes Kennedy. "We also have blocks of medical appointments every day that are identified specifically for patients referred from Sutter EDs. The navigator can go right into our electronic health scheduling system and get the patient scheduled to see a provider that day, or the next day if it is in the evening."

Address 'the whole person'

Many of the patients have complex needs that require social and medical interventions. "We often have patients come in who are homeless, and one of the more common diagnoses that they present with is diabetes with insulin dependence that is poorly managed," explains Amber Salazar, MSC, The Effort's healthcare access and case management program manager. "The insulin has to be refrigerated, which is difficult to do when you are homeless, so these patients will come through the ED frequently for a variety of issues related to their unmanaged diabetes."

The navigator will first link these patients up with a primary care provider (PCP), but then she will work on addressing the social needs. "We address the whole person, so we start with the medical condition and their case management needs; then we begin looking for a shelter or appropriate housing for them. We also address their mental health needs, so it is all integrated care," says Salazar. "Then we follow the client to insure that they are continuing to engage with the PCP and with case management services."

The navigator program was pilot tested for a year before it got the green light to proceed on a permanent basis in November of 2011. Sutter pays The Effort $150,000 per year to run the program, and as a FQHC, The Effort receives reimbursement from the government to care for patients who have no insurance or who are on Medicaid.

The ED navigator program isn't the first Sutter/Effort collaboration. The organizations first established the Triage, Transport, and Treatment (T3) program, which targets frequent ED users with more complicated needs. Administrators credit that program with reducing return visits to the ED by 65%. The navigator program's approach is similar to the T3 program, and, in fact, ED navigators can refer patients who have more complicated needs into the T3 program. In addition, many of the ED navigators — typically personnel with college degrees in human services-related fields — began working with patients as part of the T3 program before moving over to the newer navigator program.

"One of the reasons we believe our navigators are successful is because they are so closely linked with the T3 program where they can hand off individuals to that team when it is appropriate and provide an additional range of services, which includes supported housing," adds Kennedy.

Build effective relationships

To be effective, ED navigators have to earn the trust and respect of hospital personnel. "It is the relationship that gets developed with the hospital personnel that really facilitates our efforts to identify and engage with these patients," says Kennedy. "It is really kind of a teaming approach that makes it successful."

Further, as a program is being rolled out and fine-tuned, it is important for administrators at both organizations to work closely together. Kennedy notes that early on in the roll-out of the navigator program, there were regular meetings about what was working and not working, and administrators were able to remove barriers. For example, when one of the hospitals was undergoing renovations, the ED navigator got shuffled off to the radiology department, which didn't work too well, says Kennedy. With close communications between the two organizations, the problem was resolved quickly, he says.

It is also critical for the organization providing the navigators to be well-connected with community resources. "The more resources we can pull together, that really makes the navigator's job that much easier," says Kennedy.

Salazar adds that navigators should receive extensive on-the-job training. For example, she points out that The Effort's ED navigators spend time shadowing case managers, hospital staff, and the psychiatric response team.

Harper advises colleagues interested in establishing ED navigator programs to develop a solid relationship with the FQHCs in your region because they are a crucial point of access. "They will be a huge part of the capacity solution when health care reform kicks in," she says.

Salazar echoes this point, noting that The Effort's ED navigator and T3 programs are perfectly aligned with the mission of accountable care organizations and health care reform going forward. "That is really important, and more of the physicians and hospital administrators are recognizing that," she says.


  • Holly Harper, Regional Community Benefits Manager, Sutter Health, Sacramento Sierra Region, Sacramento, CA. E-mail: harperh1@sutterhealth.org.
  • Rodney Kennedy, MFT, Director, Behavioral Health Programs, The Effort Inc., Sacramento, CA. E-mail: rkennedy@theeffort.org.
  • Amber Salazar, MSC, Manager, Healthcare Access and Case Management Program, The Effort Inc., Sacramento, CA. E-mail: asalazar@theeffort.org.