Implementation of a peer health navigator program for patients at risk of frequent hospitalisation

BACKGROUND: Individuals at risk of frequent hospitalisation often experience complex health and social challenges. Peer health navigation programmes have emerged as a promising strategy to support these patients, improve continuity of care, and reduce hospital use. The strategy has strong alignment with the transition of care management model. OBJECTIVE: To describe the baseline demographic characteristics, self-reported health status, and frailty of patients enrolled in the Northern Patient Watch (NPW) program. NPW employs peer health navigators, under the supervision of health professionals, to support individuals at high risk of recurrent hospital admissions. METHODS: This observational study examined all patients who enrolled in the NPW programme between November 2021 and October 2024. Baseline data were collected on demographics, health-related quality of life (EQ-5D-5 L), and frailty (Rockwood Clinical Frailty Scale). Descriptive statistics were used to summarise the findings. RESULTS: A total of 650 patients were enrolled. The mean age was 70 years, and 56% were female. One-third lived alone, and 29% spoke a language other than English at home. The mean EQ-5D-5 L index score was 0.72, with a mean EQ-VAS of 58.9, indicating moderate health-related quality of life. Moderate issues were frequently reported across all EQ-5D-5 L dimensions, particularly in mobility, pain, and mental health. Two-thirds of participants were classified as vulnerable or frail. CONCLUSION: Patients who enrol in peer health navigation programmes such as NPW are typically older adults with moderate but not severe health challenges. These individuals may be particularly well positioned to benefit from early, tailored support that can prevent further deterioration. Findings highlight the potential value of peer navigation programmes in engaging at-risk populations before health crises occur.