Sustaining a Promising Clinical Practice in High-Turnover Rural Environments Through the Geriatric Referral Navigator...

Sustaining evidence-based health care programs is challenging, especially in clinical settings with high staff turnover. GRECC Connect is an evidence-based telemedicine service that provides geriatric specialty care to rural patients through a hub-and-spoke model between US Department of Veterans Affairs medical center "hubs" and community-based outpatient clinic (CBOC) "spokes." Four geographically diverse GRECC Connect hub sites (of 19 total) volunteered to implement a "geriatric referral navigator" role to address the challenge of sustaining use of this program in rural CBOCs.

This study aimed to understand how a health care program such as GRECC Connect can design and implement a navigator role to sustain use of its services.

We conducted a longitudinal qualitative study using a case study approach. Participants were GRECC Connect hub site staff, including program directors, coordinators, and analysts from a range of disciplines, including clinical pharmacists, geriatricians, and social workers. Over one year, we conducted 31 qualitative interviews (5 to 9 "periodic reflection" meetings and 2 semistructured interviews at each of the 4 sites) focused on key tasks, skills, and characteristics of the geriatric referral navigator role along with perceptions about the role's value. Each of the group interviews involved 2 to 4 staff members (N=10). We conducted directed content analysis using a rapid analytic approach and then shared deidentified preliminary findings at a national GRECC Connect online meeting where staff from all 19 hub sites (n=40) reflected on the role. We summarized and compared the perspectives shared during that meeting with the data we collected and analyzed from the 4 participating hub sites.

Key navigator tasks included building relationships, providing education, monitoring and troubleshooting logistical and technological issues within and across CBOCs, and evaluating the appropriateness of referrals. While professional backgrounds varied, navigator traits deemed essential for success included being flexible, creative, and a problem solver with deep institutional knowledge. The time needed to conduct navigator tasks-between 15% and 70% of the time required of a full-time employee-was substantial. The navigator role resembles several roles described in the literature that are meant to support program implementation and service use, including internal champions, external facilitators, and clinical navigators. Navigator tasks reflected a combination of known "semivisible" implementation strategies that hub site staff considered necessary not only for initially implementing the program but also for sustaining use of GRECC Connect in rural clinical environments with high staff turnover.

The geriatric referral navigator role encompasses a broad array of recognized implementation strategies. It is critical to invest in supporting the types of tasks and strategies implemented by the geriatric referral navigator to maintain promising practices over time, where appropriate, to avoid the costs and burdens of implementing new, similar programs in the future.