“The studies detailing our CareThrough ED Navigators have reached national publications in part because the work we are doing to address population health is replicable, and moves the needle on social determinants of health.”

An emergency department led by a determined provider with a keen eye for seeing the big picture, without losing site of the details, created lasting results for the uninsured members of a Colorado community by deploying Emergency Department Navigators.

As healthcare providers struggled to tackle social determinants of health and manage population health outcomes, evidence based approaches seemed few and far between. The Emergency Department saw a high volume of uninsured and Medicaid patients utilizing the ED for primary care. When the numbers continued to rise, the care team met to discuss solutions.

The leaders of the university health system knew they had to redesign care delivery to strategically align providers with the patients who presented with life threatening and critical ailments. A provider with memories of navigating healthcare as an uninsured child, remembered how her mother also utilized the emergency department and set out to provide her patients with the navigation services she didn’t have access to decades ago.

“There were patients crowded in the hallways waiting for care. Now that we have a system to connect them with the proper community resources, our team better manages patient flow.”

The ED provider devised a plan to bridge the gap to better health for their non-acute patients. Care Team Navigators were enlisted to provide non-clinical support to those with substance and opioid addiction, and families without insurance. The Navigation program was launched as a pilot to address the needs of a group of patients who had used the emergency room two or more times in the previous 180 days. The high utilization patients were asked survey questions on social determinants of health to determine their precise barriers to care.

The Navigator program also improved care plan continuity. When a navigator ended a shift, they were able to leave a note directly in the EMR to prompt the next navigator on duty to continue the process of finding the patient the community resources needed for better health. Today, higher utilization patients are connected with advocates, and new patients have access to alert emergency medicine providers, no longer bogged down with the task of helping patients navigate non-acute care

“Sometimes you get to know a patient by name because they come into the ED so often. It’s incredibly evident in the emergency environment that healthcare challenges exist that cannot be fixed by medicine alone. It takes a consistent strategy to lead patients in the right direction. You can tell it’s working when you haven’t seen a patient in a while, and the CTA can point out in the EMR where the patient is in their care journey. Overall, fewer patients fall through the cracks.”