Depiction of a Novel Patient Navigator Program to Support Delayed Discharges Among Older Adults Admitted to Acute Care

Abstract

In Canada, when a patient is deemed to be medically stable and no longer requiring acute care, they are identified as requiring an "alternate level of care" (ALC).® The contributing factors for ALC include capacity issues in hospital and other parts of the health-care delivery system, such as lack of available home care, community services or long-term care beds.®) As per CADTH Health Technology Review (2024), it is important to prevent older adults from presenting to the hospital, and/or to transfer them to transitional care programs. [...]community-based transitional care programs are heterogenous, in which services may include case management, discharge planning, support with activities of daily living, rehabilitation therapy, meal preparation, housekeeping, transportation to appointments, medication administration, assistive medical devices/equipment, referrals to community supports, and self-management.5 From 2016 to 2023, there were 45 hospital-based, 32 facility-based and 42 community-based transitional programs in Canada to support older adults.) While there are some guidance on eligibility criteria (i.e., post-acute illness, surgical procedure, or complex chronic conditions) and program length (Le., between 3 to 4 months, up to 6 months), various service providers were identified. There is growing evidence for the efficacy of PNPs for improving patient outcomes, including referral to appropriate services, better care transitions, and high levels of patient satisfaction. Since patient navigators are often involved in multiple activities, including facilitating access to care for their patients through case management or care coordination, 1t is uncertain which specific interventions leads to positive patient outcomes.(?) Hence, obtaining a better understanding of PNP service provision would help inform what constitutes patient navigation, as well as generating knowledge regarding its implementation and impact for older adults and their care partners.' Since this was a retrospective cohort observational study, participant consent was not obtained.