Section of General Internal Medicine, The University of Chicago, Chicago, IL, USA.
Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, IL, USA.
J Gen Intern Med. 2024 Jul;39(9):1616-1624. doi: 10.1007/s11606-023-08590-w. Epub 2024 Feb 12.
Healthcare systems are increasingly screening and referring patients for unmet social needs (e.g., food insecurity). Little is known about the intensity of support necessary to address unmet needs, how this support may vary by circumstance or time (duration), or the factors that may contribute to this variation.
Describe health navigator services and the effort required to support patients with complex needs at a community health center in East Oakland, CA.
Retrospective analysis of de-identified patient contact notes (e.g., progress notes).
Convenience sample of patients (n = 27) enrolled in diabetes education and referred to health navigators.
Navigators provide education on managing conditions (e.g., diabetes), initiate and track medical and social needs referrals, and navigate patients to medical and social care organizations.
Descriptive statistics for prevalence, mean, median, and range values of patient contacts and navigation services. We described patterns and variation in navigation utilization (both contacts and navigation services) based on types of need.
We identified 811 unmet social and medical needs that occurred over 710 contacts with health navigators; 722 navigation services were used to address these needs. Patients were supported by navigators for a median of 9 months; approximately 25% of patients received support for > 1 year. We categorized patients into 3 different levels of social risk, accounting for patient complexity and resource needs. The top tertile (n = 9; 33%) accounted for the majority of resource utilization, based on health navigator contacts (68%) and navigation services (75%).
The required intensity and support given to meet patients' medical and social needs is substantial and has significant variation. Meeting the needs of complex patients will require considerable investments in human capital, and a risk stratification system to help identify those most in need of services.
医疗保健系统越来越多地对未满足的社会需求（例如，食物不安全）进行筛查和转介。对于解决未满足需求所需的支持强度知之甚少，也不知道这种支持可能因情况或时间（持续时间）而异，或者有哪些因素可能导致这种变化。
描述在加利福尼亚州东奥克兰的一家社区健康中心为有复杂需求的患者提供健康导航员服务和所需的支持力度。
对未经身份识别的患者联系记录（例如，进展记录）进行回顾性分析。
参加糖尿病教育并转介给健康导航员的方便样本患者（n=27）。
导航员提供有关管理病情（例如，糖尿病）的教育，启动和跟踪医疗和社会需求转介，并引导患者到医疗和社会保健组织。
描述患者联系和导航服务的流行率、平均值、中位数和范围值的描述性统计信息。我们根据需求类型描述了导航使用的模式和变化。
我们确定了 811 项未满足的社会和医疗需求，这些需求发生在与健康导航员的 710 次联系中；使用了 722 项导航服务来解决这些需求。患者接受导航员的中位数支持时间为 9 个月；约 25%的患者接受了超过 1 年的支持。我们将患者分为 3 种不同的社会风险类别，以说明患者的复杂性和资源需求。排名最高的三分之一（n=9；33%）根据健康导航员联系（68%）和导航服务（75%）占资源利用的大部分。
满足患者医疗和社会需求所需的支持强度和提供的支持力度都很大，而且存在显著的差异。满足复杂患者的需求将需要在人力资本方面进行大量投资，并需要一个风险分层系统来帮助确定最需要服务的患者。
