Improved Access to Care for Vulnerable Patients via Health Navigator Program: Health Improvement Partnership of Santa Cruz County

Rationale / Objectives

Health Improvement Partnership (HIP) of Santa Cruz County wanted to build new systems of care and strengthen the county’s safety net in order to ensure and improve access to care for the growing high-risk, uninsured or underinsured members of its population. The various providers of healthcare had limited understanding of each other’s expertise and mutual challenges. The Health Navigator Program was undertaken as a team approach to target and connect with high-risk patients.

Project/Program Description & Major Achievements

HIP of Santa Cruz used IHI’s Triple Aim framework as an improvement guide. They used data to show the necessity for change and to create the urgency to drive that change. They targeted low-income, unassigned and uninsured patients who had frequent emergency room visits or hospital admissions. The original Health Navigator pilot project shifted its focus to providing wraparound team care, which resulted in a more than 6% reduction in readmission rates. Over 140 patients were enrolled in just over a year.

Lessons Learned

HIP found that people responded to data. Leveraging data to provide the impetus for change and to measure the impact of that change was key to engaging stakeholders. A wraparound team care approach was more effective, especially for a diverse population like Santa Cruz, in helping patients navigate the healthcare system, rather than employing a single community educator.

Further Description

Triple Aim is an IHI initiative that facilitates the collective advancement of the triad of improved experience of care, improved population health, and reduction of the per capita cost of care. HIP of Santa Cruz County is a non-profit coalition of public and private stakeholders. It serves as the backbone that supports the county’s Triple Aim efforts and projects. To set the Health Navigator Program in context, the numbers of young entrepreneurs and undocumented immigrants in Santa Cruz were growing. Both groups had limited access to health insurance. Seventy-five percent of HIP’s safety net clinic patient population was living below the poverty line, and a subset consisting of almost seventy percent of that population was Latino. The federally funded Health Navigator pilot ran from 2009 to 2011. A single community educator was hired to help connect the different players in the local health network. This highlighted the need for wraparound team care. A steering committee came together to guide this new insight to reality. HIP coordinated the project. Funding for the Health Navigator Program was provided by Santa Cruz County, the Health Home Innovation Fund, the California Wellness Foundation, and other state foundations. The county Health Services Agency contributed skilled professionals to help with the project.  A nursing consultant was hired to educate the nursing staff in public health strategies. An algorithm was designed to link patients to a particular clinic based on admission and other criteria. A hospitalist oversight committee was developed to revise the algorithm. A field was added to the Electronic Medical Record to enable patients to be flagged by the hospital social worker. The project started with a targeted 5 patients, and was increased 5-fold in stages to a total of 140 patients after 14 months.

Major Achievements

Metric Result Additional Detail
Total program enrollment 140 patients From October 2012 to December 2013
30-day readmission rates Decreased from 11% to below 5% By December 2013