Using patient navigation to facilitate utilization of available community resources in patients with or at risk for type 2 diabetes

Overview of Referral Process to Patient Navigators Patients with type 2 diabetes or at risk for diabetes may benefit from services provided by community-based organizations (CBO). Primary care physicians (PCP) are well positioned to identify individuals who could benefit. PCPs cannot easily maintain up to date information on CBO. Patient navigators (PN) maintain data resources and use motivational interviewing approaches to link patients to suitable programs.

Patient Navigators: Start-Up Compile a list of community resources for patients with diabetes and at risk for diabetes. The Community Action Team can help to populate a list of resources. Learn, improve, and use a patient tracking data mechanism. Get involved in project orientation for participating practices and CBOs. Establish a two-way data transfer for referral and tracking between the PN, CBO and practices.

Patient Navigators: Ongoing Provide patient navigation services for referred individuals according to the outlined plan. Provide feedback to participating practices, patients, and CBO. Maintain and update patient tracking information (including notes of calls, number of phone calls including unsuccessful attempts and time spent on each call/communication). Provide regular (e.g., quarterly) reports on patient navigation to the project team.

Navigators’ Actions (step-by-step): Upload patient information and referral forms into the patient data tracker. Contact the patient. Explain the program and process to the patient. – Use a scripted paragraph explaining the program protocol and expectation. Interview the patient using a series of open ended questions that, while still falling under the practice of motivational interviewing, would also provide a uniform approach. – On a scale of 1-10 how satisfied are you with your level of diabetes management? – What would it take to move you from a 2 to a 7 ? (for example) Answers may include meal plan, exercise or access to education or medications. – May I suggest a community resource? Direct the patient to a community resource. Notify the community resource of the referral. Update the referring practice. Follow up with the patient in 1-3 weeks (notify the practice of patient status). Note all correspondence.

Patient Navigation Workflow