Navigator Tool: Linking Patien

Preferences and Needs to Progr

Bree Holtz, PhD

bree.holtz@va.gov

Ann Arbor VA Healthcare System
Past Literature

• Previous Navigation:

– Cancer Care & Pediatrics– Who has been the Navigator Navigator– Outcomes

• PACT: N i av gation

– Shifted paradigm– Improve patients’ access to services

– Engage in shared decision making
‐

Navigator Navigator in PACT ‐ Objectiv

Objectiv

• Patient Patient‐centered centered care• Non‐traditional traditional care options options• Care coordination• Match patients to programs based on t

needs and preferences
The Navigator Navigator Tool

Identification/

Registry

Assessm

Follow‐up

Program

Recommendation
The Navigator Navigator Tool

Not a “case management” too
Domains

• (Chart review)

• General Patient

Information

• Cognitive Questions*• Depression• Living Situation

• Social Support

• Literacy*

• Tobacco Use• Alcohol Use

• Medication Adhe• Self‐Care Manage

Adherence

• Frailty

• Pain• Self‐Efficacy• Fall Risk*• Transportation• Technology Use• Health

Priorities/Prefere
Initial Assessment –

Depression
Initial Initial Assessment Assessment ‐ Depress

Depress
Initial Initial Assessment Assessment ‐ Depress

Depress
Initial Initial Assess – Living Situat

Situat
Initial Initial Assessment Assessment – Health Prio

Prio
Initial Initial Assessment Assessment – Technology 
Initial Assessment – Program

Recommendation
Resource Guide

https://vaww.visn11.port l a .va.gov/ it s es/Ann‐A br or/hsrd/AAVAPRG/P d/AAVAPRG/Page

/

Initial Assessment – Program

Recommendation
Note
Patient Characteristics

• Average Average patient patient is a 67 year old male• Cognitively healthy (93%)• Is not depressed depressed (only asked the

PHQ‐2)

• Live with spouse or SO (56%)• Has someone come to appointment

with him (50%)

• Drives (73%)
Patient Characteristics

• Would rather not come to the VA for pr

pr

(74%)

• Comfortable using the phone (83%)

• Has a computer that he uses regularly (

– Has access to the internet (63%)
HealtheVet

93 P ti t Rf l 

t d d f ll 

Program Referrals

Technology‐Based Programs:

167 Patient Referrals

My HealtheVet (24%)

Enh

My (24%) 168 PatieTele‐RN Case Management (16%)

CCHT (13%)TeleMove (11%)

RN Case Man

CVD Risk 

CarePartners (10%) Diabet

Initial Navigator 

Assessment

Traditional Care: Refused 

N=358

93 Patient ReferralsSocial Work (18%)

Primary Care Provider (11%)

Ph i (3%)Pharmacist (3%)Geriatrics (1%)

Education and follow‐
f

The Navigator System:

A Patient Patient Story of Prevention Prevention

62 yr old male Vetera

referred to social work 

financial financial issues; issues; his ho

in foreclosure. He h

plans as to what to 

“Thank you for all you

I got names of agenci

are helping me keep 

house; I didn’t think a

cared.”
Patient Feedback

“It’s nice that the VA cares enough these questions”“I am not concerned concerned about my diab

diab

more concerned about my wife’s ca

“It’s nice that a nurse would take tout and call me”“I didn’t know you had different different th

can do”
Implementation Challenge

• Stand

‐alone system

• Teamlet

formation

• Space
Nurse Feedback

The Navigator may open up more cfor patientsThis will help prevent prevent re‐admission

admission

care visits, and walk‐ups

Older Veterans use technology morthoughtThe N i av gator will h l e p patients to 

through the cracks
Navigator Development Tea

Wendy Morrish, Diane Hooker, Jenny Da

Masserang, Molly Harrod, Jess Ott, Sarah 

Bree Holtz

Questions: bree.holtz@va.gov
Using Peer Mentors to Impro

Diabetic Outcomes
Using Peer Mentors to Improve Diabetic

Outcomes

Judith A

CHERP Pilo

NIA Roybal Center 1P30AG0

1P30AG0

NIDDK R01 DK087
 What are we good at?

 Improving processes

 Checking blood tests (Hba1c, LDL)

Diabetes Diabetes Care and Outcomes Outcomes

 Ordering appropriate care – retinal exams

are we

O d i i i l

 Performing office based care – diabetic foot exams

 What are we bad at?

 Improving intermediate and long term clinical outcomes

 e.g. improving HbA1c, avoiding micro‐vascular complications

 Especially for low income and minority populations
Life

Family/friendsSocio‐economic factorsCultural factorsNeighborhood environmentCommunity supportAccess to carePolicy ...

Health System

P id

Patient

Provider

Hours awake per year ≈ 6,000: Hours with providers per year ≈

Need interventions that follow a patient out of the health care 
Peer Intervention Models

 Group‐based self‐management

 Involves professional support Usually conducted within the confines of the health care 

 Peer community health workers/Peer health navig

 Peers are semi‐professionals professionals and usually usually salaried salaried

 Peer coaches or mentors

 Most flexible and informal Can occur anywhere Heisler. Fam Pract 2010

Webel et al. AJPH 2010
Peer Mentors

 Usually have same culture, language, and disease p

 Often from the same community

 Innately culturally sensitive

 Modes of delivery

 Face‐to‐face Telephone based

 Web and e‐mail based

Heisler. Fam Pract 2010Webel et al. AJPH 2010
Peer Mentoring and Financial Incentives t

Improve Glucose Control in African AmericVeterans. A Randomized, Controlled Trial

Judith A

E

Diane M. Richa

George Loewe

Kevin Volp

Ann Intern M
Design

 6 month long, randomized controlled trial

 Participants

 African American, veterans, 50‐70 years old Enrollees: persistent poor DM control

 Last two HbA1c > 8% with last measure being within 3 

enrollment

 Mentors: currently in good DM control

 HbA1c of > 8% in the past 3 years and an HbA1c ≤ 7 5%. 

months of enrollment
Procedures: All Enrollees

 HbA1c drawn at enrollment and 6‐month

 Notified of baseline and final HbA1c and provided w

and VA recommendations for HbA1c targets

 Monthly calls assessing for hypoglycemic symptoms 

serious adverse events

 $25 to enroll and $25 to complete final HbA1c
Intervention Procedures

Mentor Arm Matched Matched to mentor by gender and age (+/‐ 10 yea Mentors:

 1 hour one‐on‐one training with RA Provided with mentee’s phone number

 Called monthly to reinforce training

 $20 per month if talked at least 4 times in month

Incentive Arm Lump sum for achieving goal at 6 months : $100 fo

point improvement, $200 for 2 point improvemen

HbA1c of 6 5%.
Analysis

 Intention‐to‐treat

 Main outcome: change in HbA1c

 Missing follow‐up:

 If an HbA1c was found in the medical record around tim

follow‐up (+/‐ 4 weeks), used record HbA1c

 If no HbA1c in the medical record used multiple imputa
i ( )

( )

Study Flow Diagram

Assessed for

eligibility (n=642)

Excluded (n=525)

Not meeting criteria (n=366)

Declined (n=74)

Other (n=84)

Control (n=39)

Received intervention (n=39)

Peer Mentoring (n=39)

Received intervention (n=38)

HbA1c < 7.5% (n=1)

Financial 

Received in

Analyzed (n=39)

1 abstracted

2 imputed

Analyzed (n=38)

3 abstracted

3 imputed

A

p p 
Participant Characteristics Participant Characteristics

Arm

1

Control (39)

Arm

2

Mentoring (38)

In

Mean Age, ( ) SD 59.8 (4.4) 58.8 (5.1) Education <12,

% 64.1 68.4 

Married,

%

4

6

5

8

On Insulin,

% 71.8 71.1 

Diabetes >10 years,

% 66.7 55.3 

Any DM Co‐morbidity morbidity, % 92.3 81.6 Smoker Current,

% 33.3 47.4 

All healthcare at VA,

% 74.4 73.7 

Good Adherence,

% 66.7 78.9 

Mean Baseline HbA1c, (SD) 9.9 (1.6) 9.8 (1.8) 

Mean Days Between Tests, (SD) 185 (11) 195 (15) 
Pre and Post HbA1c

BaselineHbA1c Follow‐upHbA1c

9.9 9.8 9.8

9.5

9.1

8.7

Control Peer Mentors Financial Incen

Mean Change in HbA1c Level

Usual Peer Finan

Mean Change

Usual

Care

Peer

Mentoring P Value

Finan

Incen

From Baseline(95% CI)

‐0.01

(‐0.52 to 0.51)

‐1.08

(‐1.62 to ‐0.41)

‐0.4

(‐1.02 to 

Relative to Control(95% CI)*

‐1.07

(‐1.84 to ‐0.31) 0.006

‐0.4

(‐1.23 to 

*Covariates: baseline HbA1c, marital status, insulin use, diabetic comorbid c

duration of diabetes, self‐reported adherence
C M i 

Adverse Events

Usual Peer 

Care Mentoring 

Deaths 0 0 

Serious Hypoglycemic Events 1 0 

Minor Hypoglycemic Events/Month

0, n (%) 142 (71) 107 (61) 

1‐3, n (%) 28 (19) 52 (30) >3, n (%) 21 (10) 15 (9) 

‐ All events unexpect de‐ No enrollees removed from study due to adverse events
Qualitative Feedback re Peer Men

Mentees Important that the mentor had diabetes (/) 26 28 Appreciated the support (14/28), education (9/28) Trouble getting in touch (4/28), lack of compatibility (3

 Wished for a face‐to‐face introduction (8/28)

Mentors Appreciated helping others (12/24)

 Thought it important previously been out of control (15

 Trouble scheduling (5/24), disinterested mentees (5/24 Wished for a face‐to‐face introduction (15/24)
Limitations

 One race study One institution study Financial incentives given in lump sum – did not real

immediate reward for delayed benefit

 Can not determine if the effects will persist
Study Arms

1. Control2. Peer Mentor

Completion of 6m of

Active Intervention

Comp

follow

3. Mentoring from Past Mentees

PACT Peer Mentor Study PACT Peer Mentor Study

Study Arms1. Control2. Peer Mentor

Completion of 6m of

Active Intervention

Comp

follow

3. Mentoring from Past Mentees
Conclusions

 Peer mentors had a strong effect in improving gluc

control control in a population population with persistently persistently poor cont

cont

 The peer mentor training was extremely short and

straight forward – making the intervention very ap

 Peer mentoring may be a powerful tool to reducin

disparities in glucose control and improving clinica

outcomes in minority populations

 One size is unlikely to fit all – using navigators may 

way to best fit patients patients and program program together together
Thank You

j l a ong@mail.med.upenn.eduQuestions