The Role of Community Health Navigators in the Creation of Plans to Support Patients with Chronic Conditions

Context: Community Health Navigators (CHNs) are community members trained to provide patient navigation in a primary care setting. However, the role of CHNs in providing individualized support to address unique patient needs is not well defined in the literature. ENhancing COMmunity health through Patient navigation, Advocacy and Social Support (ENCOMPASS) is a cluster-randomized controlled trial that is testing an intervention in Calgary, Alberta that pairs CHNs with patients diagnosed with two or more chronic conditions.

Objective: To explore if and how CHNs tailor their plans of support to address patient social and/or health-related needs in the ENCOMPASS trial.

Study Design: A multimethod qualitative description approach was used. Case notes completed by CHNs documenting information on patient barriers, priorities, and the CHN’s support plan for each patient priority were analyzed. Two reviewers subjectively assessed priority-CHN plans to determine the appropriateness of the plan. Patient priorities and CHN plans of support were coded separately using thematic codebook analysis, with codes being subsequently linked and quantitized to show percent correlation. Descriptive statistics was used to summarize findings.

Setting: ENCOMPASS is a partnership with the Mosaic Primary Care Network, serving an area with relatively high ethnocultural diversity and socioeconomic disadvantage.

Population Studied: Patients were 18 years or older with at least two of: hypertension, diabetes, chronic kidney disease, ischemic heart disease, congestive heart failure, and chronic obstructive pulmonary disease or asthma. Case notes for all patients who participated in the intervention between February 1, 2018 and August 12, 2021 was included.

Results: 86 patients with a total of 179 priorities were evaluated. Of those priorities, 157 priorities (88%) were assessed as having CHN support plans that had a reasonable link to addressing the priority. The strongest correlations between a priority and support plan were found for: medication adherence and CHN verifying adherence to care plan (100%); transportation and CHN facilitating transportation (90%); increasing knowledge about medical information and CHN gathering and sharing information (60%).

Conclusion: CHNs planned diverse and appropriate supports to help address patient priorities. This study can provide insight for CHNs to develop more comprehensive plans and inform the implementation of this care model.