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Health Navigators

“Thank you so much for everything you have done for me.
You will be blessed for using your whole heart to help people.
I am glad you are on my team.”

GHP member following call with HealthWorks Health Navigator


The HealthWorks Model in Person: The Health Navigator Role
Genesys HealthWorks combines a Patient Centered Medical Home with the services of a Health Navigator, who acts as part of the primary care practice team to:
  • Enhance the relationship between the patient and their primary care provider
  • Support patients in their self management and reinforce provider recommendations that may include adopting healthy lifestyles, taking medications as prescribed, self-monitoring, provider visits, and preventive screening
  • Not only focus on the highest risk patients, but place significant emphasis on keeping healthy people healthy
  • Promote healthy behaviors to prevent and manage chronic disease with the greatest emphasis on those behaviors with the most impact, such as physical activity, healthy eating, and tobacco avoidance
  • Maintain links with other health system and community resources that may assist patients in behavior change and self management efforts
  • Provide integration with the Patient Centered Medical Home to assure continuity of care and a smooth transition between the community services and various components of the health system
Health Navigator services are currently implemented in two settings with two distinct populations:
  1. Within the GPHO serving patients of primary providers participating in the patient centered medical home. For 2009 implementation at the GPHO, there were 3 HNs (3.0 full time equivalents (FTE)) at an average program cost of ~$72,000 per FTE serving a target caseload of approximately 6,000 patients per fte or average cost of ~ $1.00 per member per month.
  2. Within GHP serving low income uninsured adults enrolled in the plan. In the GHP implementation, there are 7 HNs (3.9 FTE) at an average program cost of ~$69,000 per FTE serving a target caseload of approximately 6,500 members per FTE or average cost of less than $0.90 per member per month. HNs at GHP include nurses, social workers, and health educators. Including a broad range of backgrounds on the HN team can help bring the overall program cost down as well as create a well rounded team.
Health Navigator Engagement Process:
  1. Start of the patient engagement process: The Health Navigator begins by contacting a patient:
    • After the patient sets a health goal with their GPHO provider
    • Identified upon GHP enrollment with prevention or chronic needs (smoker, diabetes, perceived poor health, asthma, pain, depression, etc.)
    • Following an ER visit to address prevention, acute and chronic needs
    • Referred by a provider or community agency with acute or chronic needs
    • Identified upon GHP enrollment with acute care needs
  2. First HN interaction (either in person or through a phone call): The HN develops rapport with the GHP member and spends 45 minutes – 1 hour talking with the individual to assess his or her needs. The HN engages the member in discussion about their health and readiness for change. If the GHP member is ready to make changes to adopt a healthier lifestyle, the HN supports the patient in setting a health goal that fits their readiness to change and links the patient to appropriate community resources and education materials.
  3. Follow-up calls are made to the member at a frequency based on their individuals needs. During the follow-up period, HNs work to develop strong supportive relationships with members, which are crucial to meeting people where they are and supporting self management. Members may, however, work with multiple team members over time. The key is that patients view all the Health Navigators as a team, who are working together to support them through their lifestyle changes.
  4. Health Navigators develop and update Community Resource Guides to meet the needs of their members; for example assisting, a member in finding an appropriate recreation facility for physical activity, bus passes to travel to and from medical appointments, or prescription assistance.
  5. All members are supported over time and reassessed at three and six months to monitor their progress towards their goal.
The HealthWorks Model in Action: Making a Difference in Patient Lives

Making Positive Changes: One GHP Patient’s Story:

Mr. D is a 39-year old male with a six year history of hypertension, who is a member of GHP. Following an admission to the hospital for uncontrolled blood pressure, Mr. D was contacted by a GHP Health Navigator. During their initial telephone call, the Health Navigator engaged Mr. D and listened to his story and concerns. As the Health Navigator assessed his needs, she identified that Mr. D had stopped taking his medications a few years ago due to his lack of insurance. Due to his high blood pressure, Mr. D was unable to pass his employers required physical and was not able to work. Mr. D was also experiencing high stress due to a recent divorce and financial pressures. Mr. D also stated he had been reluctant to go to the hospital due to the cost and was concerned about how he was going to pay the bill for his recent admission.

During their call, the Health Navigator offered support to Mr. D, assuring him that he had access to his primary care physician for follow-up appointments through GHP and encouraged him to build a relationship with his provider. The Health Navigator linked Mr. D with the hospital’s Charity Care Coordinator to assist him in covering the cost of his admission. In addition, the Health Navigator connected Mr. D to the GHP Prescription Assistance Program to help him obtain his medications. The Health Navigator also engaged Mr. D in discussions regarding healthy eating, exercise, and smoking cessation, helped him identify areas he wanted to improve and where he could begin to fit these behavior changes into his lifestyle.
Following their initial conversation, the Health Navigator contacted Mr. D periodically over the next 3 months to support his progress on his identify behavior changes.

During their three-month follow-up call, Mr. D stated he had developed a relationship with his primary care physician and was visiting the office regularly. Mr. D was taking his medications as prescribed, and was back at work driving his truck after passing his physical. Mr. D was also packing fruits and vegetables in his lunch at work for snacks to supplement “Truck Stop Food” and had switched to Mrs. Dash for seasoning instead of salt. Mr. D also reported that he was riding his bike regularly for exercise and had stopped smoking. Mr. D stated that he was “feeling really good” with his new healthy lifestyle.

 

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