Patient navigator program reduces length of stay

A 442-bed acute care urban academic health center in Toronto decreased length of stay by improving patient-physician communication and handoffs.


Where: Mount Sinai Hospital, a 442-bed acute care urban academic health center in Toronto, Canada.

The issue: Improving physician-patient communication and handoffs.

Background

Effective communication is paramount to providing good patient care, but it can also be difficult to accomplish during handoffs in the hospital. As general internists with a focus on hospital care, Janice Kwan, MD, MPH, and Matthew Morgan, MD, MSc, FACP, wanted to see if patient navigators could help resolve this problem for the general internal medicine division at Mount Sinai.

Unlike traditional patient navigators who may coach patients or help navigate them through care transitions, the Mount Sinai navigators' main responsibility was improving patient-clinician communication. As members of the clinical team with no clinical responsibilities, navigators ranged in experience and did not necessarily have backgrounds in health care.

The hospital implemented the program in 2010 with 2 navigators on the division and in 2012 expanded it to 4 navigators, 1 for each of the division's clinical care teams. The hospital also added 1 navigator to surgical oncology and 1 for patients with inflammatory bowel disease.

How it works

Navigators participated in daily rounds and answered simple patient questions related to test scheduling, diagnosis, and care while relaying more in-depth questions to the clinical team. On average, navigators worked with between 20 and 30 patients daily, and each patient saw the same navigator throughout his or her hospital stay. After discharge, navigators were the primary contact for patients, and, when needed, they helped arrange follow-up appointments and placed post-discharge phone calls.

The navigators improved communication by being accessible to both patients and clinicians through a dedicated mobile phone. “This was just 1 way of keeping in touch at all times,” said Dr. Kwan, a staff physician in the division. “It was notable that patient navigators were the only consistent member of the clinical team for the patient, and they were a consistent face of recognizability for the medical team.”

Results

Adding navigators to the patient care team succeeded in reducing length of stay without affecting 30-day readmission rates, according to results published in August by the Journal of Hospital Medicine. Nearly 4 years of program data showed that patients without navigators had an average length of stay of 7.5 days compared to 6.2 days in the navigators' patients—a 21% difference. (Average length of stay is longer in Canada than in the U.S.) The navigators allowed physicians to focus more on patient care, rather than administrative tasks such as ensuring that different imaging studies were done expeditiously, Dr. Kwan noted.

On the qualitative side, patients and clinicians also reported positive results. “At least anecdotally, we got the sense that residents very much appreciated getting to work with navigators and, in particular, found that the workflow and communication was enhanced when getting the chance to work with them,” said Dr. Kwan, citing resident surveys. Patient satisfaction scores were also very good for those exposed to navigators, said Dr. Morgan, the division's site director. “The thank-you letters and the responses were always very positive,” he said.

Lessons learned

“I think one big lesson is that we should never shortchange how important communication is in health care,” Dr. Kwan said. “Especially when one is able to compare an experience with and without patient navigators, it's clear that having an individual there to be solely responsible for making sure that people are talking to each other and making sure that messages are being passed along and speaking face-to-face with people makes a big difference and… also seemed to improve objective performance measures as well.”

Challenges and next steps

Despite sustaining the program since 2010, the hospital canceled it this summer because of complicated budgetary restraints in Canada's single-payer system, Dr. Kwan said. The main cost of running the program was the navigators' salaries and benefits (roughly $60,000 to $70,000 each in U.S. dollars).

Up until this point, the program was funded by the hospital, donations directed to support new methods of care delivery, and matching funds provided by physicians within the hospital's department of medicine. Physicians supported the program because it afforded them more time to focus on caring for their patients, Dr. Morgan said. “I think that as physicians, we would say patient navigators allowed us to provide excellent patient care more effectively,” he said.

It's too early to tell if the hospital will be able to bring back the program in the future, Dr. Morgan said. “We're certainly exploring our options and rethinking and working with all the key stakeholders to figure out how we continue to provide the best care possible to all our patients,” he said.

That uncertainty doesn't have to stop other hospitals from trying a navigator program, according to Dr. Kwan. “Testing it in different environments is certainly the next step in terms of seeing if it would work in different settings, such as the U.S.,” she said.