Intensity and variation of health navigator support: Addressing medical and social needs of diabetes patients in East Oakland

Background: 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.

Objective: Describe health navigator services and the effort required to support patients with complex needs at a community health center in East Oakland, CA.

Design: Retrospective analysis of de-identified patient contact notes (e.g., progress notes). Participants: Convenience sample of patients (n = 27) enrolled in diabetes education and referred to health navigators.

Interventions: 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.

Main Measures: 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.

Key Results: 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%).

Conclusions: 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.