Adapting an In-Clinic Resource Navigator Program to a Virtual Referral Model

Abstract

With new infection control guidelines in March 2020, the navigators began working remotely, connecting with clinicians and patients by telephone. We conducted interviews with clinicians and staff to identify barriers and opportunities for screening and referring patients to the CRNP. These interviews yielded key themes-communication, opportunities to improve original workflow, and new barriers with off-site navigators. We identified clear communication, easy access to navigator contact information for referrals, and increased frequency of reminders to screen for social needs as specific targets for quality improvement.We have now developed multiple opportunities for patients to screen into and be connected to the CRNP. This multifaceted screening/referral process involves sharing updated contact information for the navigators with all staff through an electronic health record "smartphrase." Navigators join our daily clinic huddle every Monday to provide updates and reminders to clinic staff about how to connect with navigators off-site.We established a "universal screening" protocol, providing all patients at office visits with a brief handout about how to contact navigators directly.Survey results evaluating these updated workflows suggest that most clinicians are contacting the navigators for patients, with their consent. In other cases, clinicians discuss how to contact the navigators with patients, enabling patients to make the connection directly. Based on feedback from this survey we are continuing to improve 2-way communication between clinicians and navigators. LEARNINGDespite an increase in telehealth and a shift to new workflows that limited physical interactions in our clinic, we were able to use virtual workflows to continue connecting patients with resources to address their unmet social needs. We achieved this by integrating off-site community partners into telephone huddles, shared health record reminders, and telephone/e-mail connections. Other clinics can connect patients with similar social prescribing programs by providing team members and patients with multiple pathways for screening and referrals and involving community partners in regular telephone "huddles." These strategies can help reinforce meaningful community-clinic partnerships that support patients to surmount structural and systemic barriers to health.Read more or post commentaries on this article.Supplemental materials, including references, prior presentations, funding support, and acknowledgments