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Community Linkage Through Navigation to Reduce Hospital Utilization Among Super Utilizer Patients: A Case Study.

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This program connects hospital super utilizers with community resources using patient navigators and social workers. This approach improves care access and reduces hospital use for vulnerable populations.

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Area of Science:

  • Healthcare Management
  • Public Health
  • Social Work

Background:

  • Super utilizers significantly strain hospital resources.
  • Fragmented care access exacerbates health issues for vulnerable populations.
  • Existing community resources are often underutilized by those in need.

Purpose of the Study:

  • To describe a program model integrating patient navigators and social workers.
  • To improve access to community resources for hospital super utilizers.
  • To reduce hospital utilization through enhanced care coordination.

Main Methods:

  • A program model utilizing hospital- and community-based navigators and social workers.
  • Case study illustrating a homeless super utilizer with psychosocial issues.
  • Description of navigator/social worker roles, approaches, and community linkages.
  • Sharing of navigator experiences and lessons learned.

Main Results:

  • Demonstrated linkage of a super utilizer to specific community resources.
  • Shared insights into the practical application of the navigator role.
  • Presented program and patient outcomes, indicating potential for reduced hospital utilization.

Conclusions:

  • Integrated care models with navigators and social workers can effectively link super utilizers to community resources.
  • This approach shows promise in improving access to appropriate care.
  • Reducing hospital utilization is achievable through proactive community resource connection.