Understanding the Goals of Older Adults with Complex Care Needs, Their Family Caregivers and Their Care Providers Enrolled in a Patient Navigation Program.

Patient navigation models of care are being used to support hospital-to-home transitions. The present paper aimed to explore the goals important to older adults, their caregivers, and care providers as they transition from hospital-to-home and how, if at all, patient navigation can enable goals of care. Data were comprised of 94 interviews with 16 older adults, 5 family caregivers and 48 healthcare providers. Data were analyzed thematically and similarities and differences in goals were identified. Shared goals included having someone to count on and easy access to services. Older adults expressed the goal of independence, whereas family caregivers and healthcare providers noted safety. Caregivers noted goals of developing skills. While patient navigation was viewed as meeting goals of care by participants, future research is required to determine how patient navigation can support goal setting as a standard clinical practice and the long-term patient outcomes of meeting goals.