The Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review Protocol
Creators: name: Kokorelias, Kristina
name: Hitzig, Sander
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Medicine and Health Sciences

description: The Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review Protocol Abstract: Introduction: Patient navigation is a model of care that aims to reduce the complexity of navigating health, education, and social services across continuums of care and care settings. Worldwide, patient navigation is increasingly being used to improve healthcare delivery for adults with complex needs. Existing scoping reviews on patient navigation have excluded grey literature, not focused on adults with complex needs population or exclusively focused on primary care settings. Similarly, existing reviews have not considered the role of caregivers within patient navigation programs. In this paper, we outline our scoping review protocol to systematically review published and unpublished literature specific implemented patient navigation programs for adults with complex needs across all settings. Specifically, the protocol will aim to examine the literature describing implementation of patient navigation interventions and the characteristics and outcomes of the programs. Methods and analysis: Arksey and O’Malley’s scoping review methodology framework and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses extension for Scoping Reviews Checklist will guide the conduct of this scoping review. This scoping review will consist of published and grey literature for adults with complex needs patient navigation programs. Comprehensive searches of relevant electronic databases (e.g., MEDLINE, EMBASE) will be used to search for academic literature. To search for grey literature, systematic Google searches will be conducted. A review of websites of healthcare provider organisations (e.g., hospitals) will also be used to identify relevant material. We will review the reference lists of included materials to identify other literature appropriate for inclusion. Two reviewers will pilot-test the screening criteria and data abstraction form. They will then screen all citations, full articles and abstract data in duplicate independently. The Consolidated Framework for Implementation Research will serve as the theoretical framework during analysis. The results of the scoping review will be synthesised descriptively and thematically. Specifically, we will report on 1) when and how programs are developed and implemented 2) the content of programs and how these changes to meet the needs of patients and families and 3) the reported impact of these programs on patient and caregiver outcomes. Additional common themes amongst the program may also be reported on. Ethics and dissemination: This scoping review will synthesise the information around the implementation of existing patient navigation programs and their characteristics and outcomes as described in the literature. As this is a scoping review ethics approval is not indicated. Findings from this review will be useful to implementation scientists and health service researchers by identifying gaps in existing programs and evidence and for highlighting implementation strategies for adapting similar patient navigation interventions applicable to multiple care settings. The results will be disseminated through a peer-reviewed publication, conference presentations and a stakeholder meeting at a large urban hospital in Toronto. Strengths and Limitations of this Study • To the best of our knowledge this will be the first report on adult navigation programs that reflect the implementation and uniqueness of each program. • This review is guided by well-known methodological and theoretical frameworks. • This review includes a comprehensive literature search including grey literature. • We will use two independent investigators for all phases of the review. • We will only be including English-language articles published since 1990. Introduction: The world’s population is aging(1), and we are now seeing more adults living with chronic diseases (2). Adults are more likely than younger individuals to suffer from poor health and chronic conditions. Consequently, adults (defined as those 26 years and older) with complex needs (defined as adults aged 26 years and older with mixed mental, physical, cognitive, and social needs) use more healthcare services. To meet adults’ varying health and social care needs, many elements of the healthcare continuum are utilized, including emergency, acute, rehabilitation, community, and long-term care. An extensive body of literature shows that many adults with complex needs have difficulty accessing healthcare services and navigating the healthcare system, particularly following a hospital discharge (3-6). As a result of inadequate discharge and transitional planning, many patients face adverse outcomes, including morbidity and rehospitalization (7-11) . In an effort to people navigate and access health services across the care continuum, patient navigation has been proposed as an innovative intervention to address known barriers to obtaining care and achieve optimal health outcomes. Patient navigation programs originally began in cancer care but has expanded to be applied to other disease or populations (12-14) . However, there is little consensus about what constitutes patient navigation services (14), and there is little information on the efficacy of patient navigation in improving patient outcomes (13, 15). A recent review highlights that few studies assess patient experience, clinical outcomes or costs within patient navigation programs (16). In addition to supporting adults with complex needs, supporting family caregivers also remains a priority within healthcare policy. In Canada alone, eight million individuals identify as a family caregiver (friend, family or neighbour) to an individual with a disability, chronic condition or problems associated with aging (17). Family caregivers are often essential in helping adults navigate elements of the healthcare continuum (18-24). To assist them in their caregiving roles, caregivers have advocated for increased access to resources and system navigators (25). Unfortunately, there is currently little known about how patient navigation programs include the role of family caregivers in their planning, implementation and intended outcomes. This information is needed for stakeholders who plan to develop family-centred patient navigation models of care for adults with complex needs. Little is known about processes that facilitate or impede implementation of patient navigation programs. To effectively implement interventions to improve patient care into the local context barriers and facilitators to program implementation need to be explored (26). The field of implementation science lends theoretical frameworks that can inform the exploration of contextual factors that influence program development and implementation (27). The Consolidated Framework for Implementation Research (CFIR), identifies organizational and system level factors associated with program implementation (26). In the context of patient navigation, there is a wide variation in the design and implementation of existing patient navigator programs (16). No scoping review to date has summarized the characteristics of existing programs nor the facilitators to the implementation of patient navigator programs worldwide. Existing recent reviews (i.e.: those published within the past 5 years) in the area of patient navigation have tended to focus on cancer (28), fail to consider grey literature (16) where implemented programs may be described or have not narrowed their search to the adults with complex needs population (but rather all adults aged 18 or older (29), who may be better suited by youth programs (30) or pediatric populations (31)). Existing reviews also do not report on the role of family caregivers within existing programs. Methods and analysis: Study Design A scoping review methodology, which is a type of knowledge synthesis used to identify areas of consensus and gaps in knowledge, was chosen as the study design (32). Unlike systematic reviews, scoping reviews do not aim to assess the rigour of given research findings and allow for a more expansive, exploratory approach (32). The protocol for this scoping review is drafted based on Arksey and O’Malley’s five-stage methodological framework statement (33) and the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (34). Arksey and O'Malley’s method includes the following steps (1) identifying the research question, (2) identifying relevant studies, (3) screening and selecting studies, (4) charting the data, (5) collating, summarising and synthesising the results and finally, (6) consulting with stakeholders (33). Step 1: Identifying the Research Question The research team collaborated with stakeholders (i.e., a current patient navigator, representatives from a not-for-profit community support service agency, the Director of Interprofessional Practice from a large urban hospital), to define the research question for this review. Questions were also informed by the CFIR (26).We identified the following five research questions: 1.What is the scope of patient navigation programs available for adults age 26 years or older with complex needs?; 2) Who are the target patients of the existing programs? 3) When and how were these programs are developed and implemented? 4) What are the content of the programs and how does the content of these programs change to meet the needs of patients and families; 5) What are the reported impact of these programs on patient and caregiver outcomes? We define patient navigation programs as a model of care whereby a partnership is formed between a patient and/or family and the patient navigator, who aims to provide navigational support to accessing health and/or community resources and provides informational and emotional support (12, 35, 36) . Step 2: Identifying relevant studies Searches for academic literature will be conducted in Ageline, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Embase, Ovid MEDLINE(R) (including Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R) Daily), Pubmed, OTSeeker, PeDRO, PsycINFO and Scopus. We will also conduct a systematic Google search to identify adults aged 26 years or older needs patient programs. Search terms will include: Canadian senior patient navigation, USA senior patient navigation, European vulnerable patient navigator, vulnerable patient navigator, nurse navigator, adults care coordinator, family care coordinator. Reference to specific countries will be used (e.g., ‘adult patient navigation Canada’, ‘patient navigation adults Italy’). We will also search for organizations aimed at improving care coordination (e.g., ‘Sunnybrook Health Sciences Patient Navigation’). The websites of community agencies and hospitals identified through the google search will also be searched to identify grey literature (e.g., reports). The search strategy will first be developed in connection with an institutional Information Specialist. The search strategy will then be peer reviewed using Peer Review of Electronic Search Strategies guidelines (37). Bibliographic information of all references will be managed using EndNote X10 (38). Systematic de-duplication will be carried out using the Bramer method for Endnote users (39). Step 3: Screening and selecting studies First, we will screen the titles and abstracts, followed by full-text review of the selected articles. In both levels of screening, two investigators will independently screen the title and abstract of all retrieved citations for inclusion against the set of predefined inclusion criteria. Weekly meetings will occur between the two reviewers to discuss any ongoing concerns and discuss any conflicts. In the case agreement cannot be made between the reviewers in the selection process, a third team member will be consulted to form a consensus. Once all articles are reviewed, the reference lists of all included articles will be searched by the two reviewers. For the purpose of this review, articles will be included if: 1. They discuss an implemented patient navigation program in any setting (e.g., hospital, clinic or community-based settings) or a protocol for the implementation of a patient navigation program 2. The patient navigation program discuss is intended for adults (aged 26 years or older) with complex (i.e. mixed mental, physical, cognitive, and social) needs. 3. The patient navigation program is implemented or to be implemented. Only articles published from January 1990-date of submission will be included. Articles that discuss programs implemented prior to January 1990 but are published after January 1990 will be included We have identified 1990 as a time period when the first patient navigation program was conceived and when patient navigation began being conceptualised in the health service research (40). Only articles that describe patient navigation for solely for adults aged 26 years or older will be included. Systematic, scoping and literature reviews will be excluded. As consistent with scoping review methodologies, some inclusion/exclusion criteria will be determined by the research team ‘post hoc’ during the screening process (33) as we become increasingly familiar with the existing patient navigation programs. Covidence online software will guide the process of screening and selecting of studies (41). Step 4:Charting Data To ensure consistency amongst the reviewers, a data extraction form will be developed and piloted on a subset of studies. Two independent reviewers will use Covidence software to chart data from all included studies and reports. Charting the data is an iterative process (33), and therefore changes to the form may be necessary prior to the extraction of all articles. Data to be extracted includes, but is not limited to, publication type (e.g., journal article or grey literature), when and how the intervention was developed (e.g., components of the CIFR utilized), intervention characteristics (e.g., professional designation of the patient navigator, components and services provided), intervention primary setting (e.g., primary care), patient characteristics (e.g., clinical characteristics of the intended population), delivery method (e.g., face-to-face), strategies used to include family caregivers and reported patient and family caregiver outcomes. We will also extract patient, caregiver and health system outcomes, barriers and facilitators to, as well as challenges in, providing effective transitional care services. Step 5: Collating, summarising and synthesising the results We will conduct a descriptive analysis of characteristics of the included programs (e.g., credentials of patient navigators, stakeholders involved in implementation, the context of the program) as well as a qualitative thematic analysis of the influential characteristics of program implementation. We will identify areas where interventions coalesce as well as differences among each intervention. We will also report on noteworthy gaps in the literature. Additional common themes amongst the program may also be reported on. Step 6: Consulting with Stakeholders Patients and caregivers were not involved during the design and development of this scoping review protocol but may be consulted during ‘Stage 6’ to provide insights into supplement our literature review findings Through regularly scheduled meetings and communication, we will work with representatives from a community service organization and hospital. Both organizations have the strategic aim to improve patient navigation through the healthcare system. Once data are analysed, we will hold regular stakeholder consultation meetings to present preliminary findings and to solicit feedback on the final content before broader dissemination via conference presentations and publication of results in peer-reviewed journals. These stakeholders will also be invited to participate in dissemination of the findings (through presentations to local clinical and administrative audiences) to support the development of future patient navigations programs. Ethics and dissemination: The implementation of existing patient navigation programs for adults with complex needs and the program characteristics and outcomes have not yet been full explored. As patient navigation programs are gaining popularity worldwide, information that can ease the implementation process is greatly needed. The synthesis achieved through this scoping review will facilitate early identification of factors most likely to impact implementation of patient navigation interventions. Similarly, our findings will provide an overview of the existing programs, their context to meet the needs of patients and families and their outcomes. We begin this project with the support of numerous knowledge users, from a local community health organization and a large urban hospital who are keen to use and disseminate our findings. Upon study completion, we will disseminate findings to and through these organisations. Scientific findings from this review will be published in a peer-reviewed journal. As this study has the potential to inform future research, policy, and the delivery of navigation programs across the globe, we will also disseminate our findings at national conferences to share findings with the health service community (e.g., clinicians, administrators, service providers). Ethics approval is not indicated as we are not collecting primary data. Authors’ contributions: KMK conceived of the idea. KMK and SLH refined the study aims and study methods. KMK wrote the first draft of the protocol. SLH contributed meaningfully to the drafting, editing and approval of the final manuscript Funding: Kristina M. Kokorelias is supported by the Slaight Family Foundation at the Sunnybrook Research Institute. References: 1. Bohnert N, Chagnon J, Coulombe S, Dion P, Martel L. 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