Health Navigation Toolkit - Iowa Primary Care Association

Health Navigation Toolkit - Iowa Primary Care Association

D

ALLAS

C

OUNTY

P

UBLIC

H

EALTH

Health Navigation

Toolkit

2013

0

Table of Contents

Topic Area

Introduction

Issue and Vision

Page

2

3 - 4

How it Works

Outreach/Marketing

5 - 6

7

Data Tracking & Reporting 8

Appendix A - Graphic of Dallas County’s Vision

Appendix B – Health Navigation Clinic Referral Tool Sample

Appendix C – Health Navigation Screening Tool Sample

Appendix D – Health Navigation Database User Manual Example

Appendix E – Health Navigation Policy Sample

Appendix F – Health Navigation Outreach Card Sample

Appendix G – Report Examples

 Primary Presenting Issue by Type

 Referrals Provided for Access to Medical Care

 Other Program/Referrals Provided

 Barriers by Type

 City of Residence

 Tier 1 Follow up Dates

 Referral Source by Client

1

Introduction

This toolkit was compiled to share a program, Health Navigation, developed by Dallas County Public

Health (Iowa). Health Navigation is a community utility to coordinate existing services in the community and to support the patient centered medical home model. A community utility is a service that is provided to the community that everyone contributes to and everyone benefits from for something that cannot be accomplished efficiently alone, like the provision of electricity.

Locating and accessing needed services in the community can be difficult, confusing or even overwhelming. This can be true for community residents, community agencies and healthcare providers. Healthcare providers and community agencies can refer patients to Health Navigation services. And, residents looking for a medical home or additional assistance can contact Health

Navigation directly for help in locating a medical home or to be connected to existing community services/programs.

Health Navigation was developed over a 5 year period in response to a need identified by Dallas County providers and residents. Funding to support Health Navigation efforts was received from Iowa

Collaborative Safety Net Medical Home Grants, Mid Iowa Health Foundation, Community

Transformation Grant/Iowa Department of Public Health and United Way of Central Iowa. Development of this toolkit was funded by Community Transformation Grant/Iowa Department of Public Health.

While information shared in this toolkit is specific to Dallas County, it is hoped that tools and lessons learned can assist other local public health departments and community coalitions. Health Navigation can be used to help support integrated care models and a redesigned care delivery system.

For more information on Dallas County Health Navigation, contact Shelley Horak [email protected]

2

Issue and Vision

Identify the Specific Gap/Issue

Health Navigation was developed as a response to an unmet community need. When identifying a specific gap or issue in the community, it is important to reach out and get input from a broad group of people. This includes:

Current coalitions/partnership groups

Community partners

Residents

Stakeholders/key informants

Primary Care Providers

Those not previously worked with but who may have an interest

Gather Information and Data

It is also important to gather information and data as evidence of the issue’s existence and impact on the community. Sources of data and information available in the community might include:

Community Health Needs Assessment http://www.idph.state.ia.us/chnahip/HealthImprovementPlans.aspx

Hospital Emergency Department Use

Hospital Readmissions

Number and/or percent of uninsured, Medicaid, chronic health issues, etc.

Anecdotal stories

Clarify the Vision

Once the issue has been identified and information regarding the issue has been gathered, the community must come together to clarify a vision for addressing the issue. While agreement on all details of a solution is not necessary, a general consensus of vision is critical to the future success of the project. Following are some suggestions and considerations when clarifying the vision:

Brainstorm with your coalition

Consider using an outside facilitator

Discuss and focus on key words and themes that emerge

Think about scope and manageability

Make sure there is agreement/buy-in from key partners

Emphasize the vision belongs to the community, not one agency or faction

Consider creating a graphic of your vision; this can make the vision easier to share with the broader community and potential funders

Dallas County’s Issue & Vision

Dallas County’s Partnership for Health utilized information from the Community Health Needs

Assessment and interviews with key informants to identify the issue as “lack of access to care and confusion regarding community resources and programs including eligibility, benefits, and application processes”. In an interview one of the key informants described the situation as, “. . . a patchwork of

programs/resources with no central point of information or coordination”.

4

Dallas County Partnership for Health determined the need for an online Resource Directory and a Health

Navigator. The vision statement:

“Residents of Dallas County will have access to available resources in the county through one point of contact, with emphasis on timely referrals, fewer steps to receipt of care, efficiency, increased options and improved outcomes.”

Based on this vision, a graphic was developed Graphic of Dallas County’s Vision (Appendix A).

5

How it Works

The Nuts and Bolts of the Program

When developing a program based on the vision, it’s a good idea to start by asking questions. Here are a few to get started:

Has anyone done this or something similar?

Can we learn from their attempts and mistakes?

Have we checked with IDPH, the Iowa Collaborative Safety Net Network or others who may be aware of similar projects?

Have we done an internet search for related projects/ideas?

Have we talked with or visited those identified to learn more?

There are many items to be considered when planning a new project/program. Considerations include:

Mode/location of interactions (phone, face to face, office, home, clinic)

Depth of involvement with the patient/client

Staff functions and job descriptions

Tools, forms, training required

Interpretation and translation; if so, what languages are needed

Policy and procedures; best practices

Implementation timeframe

Cost, both start-up and ongoing

Dallas County’s Nuts and Bolts (aka How it Works)

A healthcare provider or community agency can refer an individual to Health Navigation; or, a resident can self refer. Referrals from healthcare providers are considered Tier 1 referrals and given priority. All other referrals are considered Tier 2 referrals.

If the referral is from a healthcare provider, a Clinic Referral Tool (Appendix B) is completed by the healthcare provider and faxed to Health Navigation. The Health Navigator contacts the client within 3 days and utilizes the Screening Tool (Appendix C) to gather additional information. Based on the information gathered, the Health Navigator assists the client in obtaining appropriate resources. This could include access to and payment for medical care including medications; mental health/substance abuse treatment; basic needs such as food or safe, affordable housing; parenting/childcare; or aging issues.

Information on client, source of referral, contacts and referrals provided is entered into the database in accordance with the Health Navigation Database User Manual (Appendix D). The Health Navigator makes follow-up contact with the client in accordance with Health Navigation Policy (Appendix E). If the original referral was Tier 1, from a healthcare provider, information is provided back to the healthcare provider regarding Health Navigator and client actions.

From the start, it was deemed important to the success of the program that Health Navigation be clientfocused. Client-focused characteristics incorporated in Health Navigation include:

Active engagement of the client

Focus on client’s current need

Provide the client information and support to make decisions

6

Respect client choice and empowerment

Mode/location of the contact should be determined by client (phone or in-person; home, office, library, Burger King)

Client guides the level of screening tool information collected

Health Navigator will provide hands on assistance (applications, paperwork, interpretation) when necessary and with the client’s request/permission

Level of involvement, number of contacts and timeframe will be driven by the individual client and situation

The staff range of skills and knowledge needed for Health Navigation is broad and includes:

Local, state, federal resources

Children and families

DHS, Medicaid

Aging, Medicare

How insurance works

Health/Medical

Based on this range of knowledge and skills, the model developed in Dallas County decided to utilize a team approach including a nurse, social worker, and community health worker.

7

Outreach/Marketing

Getting the Message Out

Once the program is developed, it is important to get the word out. Explaining the program and how it works isn’t always as easy as it seems. One message does not fit all audiences. Tailor the message to the audience. Continually “market” the program. If a healthcare provider has not utilized or referred to the program for a while, the provider may have forgotten how the program works. Keep the program in the forefront of the provider’s vision, remind them frequently and make it easy for them to refer to the program. Here are some important aspects to getting the message out about the program:

Name & branding

Who is the target audience?

Do some research on your target audience

Highlight what the program can do for the target audience

Letting the audience know what you can’t do is as important as letting them know what you can

 do

Try to show how the program/service fits into the big picture

Find champions

Recognize each clinic/healthcare provider setting is unique

Dallas County Messaging

A Health Navigation Outreach Card (Appendix F) was developed and distributed to healthcare providers, community agencies and libraries. The card outlines what Health Navigation can do to help:

Screen for needs and refer/assist client in obtaining needed services and resources

Help with access to; and, payment for medical care

Help with access to medications

Connect to non-medical community services such as housing, heat assistance, childcare, food, etc.

In presentations to healthcare providers it was important to highlight what Health Navigation was NOT:

Emergency service

Case management

Health coach

Discharge planner

BUT it can assist all of these

The big picture of Health Navigation benefits to patients, providers and community was highlighted for healthcare providers, government, community partners and funders including:

Access to payment source/meds

Help address underlying social issues

Can reduce ER visits, hospital admissions and readmissions

Maximizes resources

8

Data Tracking and Reporting

Data tracking and reporting is critical to a successful program. Data measures can track quantity and quality; describe who is being served; and, measure the impact or difference the program is making in the community. The data also informs revisions or adjustments that may need to be made to improve the scope and quality of the program. As important as collecting the data is reporting the data. Reports allow staff, community partners and funders to view the data in a format that allows for description, trends and comparison.

Decisions

Prior to program implementation, there are a number of decisions that need to be made. The first decision is how will data be tracked:

EMR

Excel

Other database

What will you track? Think about meaningful reports (process, descriptive and outcome); base the data tracked according to reports needed/wanted.

Demographics

Contacts

Referrals

Outcomes

Barriers

Follow-up dates

Notes

Dallas County’s Data Tracking & Reporting

Based on financial constraints, Health Navigation was initially done on an excel spreadsheet. As referrals increased and the program grew, the need for a more robust tracking system became apparent. A programmer was retained to help develop an access based Health Navigation tracking and reporting system. The Health Navigation Database User Manual (Appendix D) contains more detailed information.

Examples of reports created and utilized for Health Navigation include (Appendix G):

Primary Presenting Issue by Type

Referrals Provided for Access to Medical Care

Other Program/Referrals Provided

Barriers by Type

Demographics (example – city of residence)

Follow up dates (example - Tier 1)

Referral Source by Client

9

Appendix A

Collaboration, Funding, & Education

Patients

Primary Care

Partners

Health Navigator

& Website

Community Partners

Agencies

Government

Increased Efficiency, Health Equity, & Improved Quality

Appendix B

Sample

Health Navigation

Clinic Referral Tool

Fax xxx.xxx.xxxx Phone xxx.xxx.xxxx

Clinic Name:

Name:

Phone:

Date:

DOB:

Release of Information authorizing exchange of information obtained?

Yes

Areas of Need

Help w/ Medical Insurance or Payment source

Medication Assistance

Parenting Skills Counseling Dentist Food

Utilities Assistance Child Care Veterans Tobacco

Substance Abuse

Domestic Abuse

Elderly Issues Housing

Financial Assistance Employment

Education Issues

Other

Maternal Child Health/ Child Development Issues

Reason For Referral

Appendix C

Health Navigation Screening Tool

Date of Referral:

Referral From:

Referral Reason:

Identifying Information

Date of screening

First Name

Address

Phone

Household Members

Name

Phone

MI Last Name

Relationship

Date of Birth:

Birth Date

Medical Information

Medical Home Yes No Provider Name

Clinic Name

Health Insurance

Underinsured

Private

Medicare

Fear

Hawk-I

Other

Insurance Information & Number

Veteran Status Yes No

Meds for physical conditions

Pharmacy

If Medicare, Part D? Yes No

Dental Provider Yes No Date of Last Visit

Barriers to Medical Care

No Insurance Unpaid Bill Transportation

SA/MH

State Plan

None

Hours

Medicaid

1

Financial Information

Current/Last Employment

Hours Wage

Income

Employment Self Employed

IPERS Veterans/Military

Family/Friends

Monthly Payment

Other Expenses

Electric Phone/Internet

Gas

Child Support

Garbage

Support

Section 8/Low Income/Sr & Dis

Kind of Work

Unemployment

Child Support

Social Security

FIP

Financial Resources

Cash

Disability/SSDI

Rent

SSI

Investment Income

Checking

Burial contract/Plot

Housing Information

Own Rent

Savings

Homeless Shelter

Retirement/Pension

Other

Stocks/Bonds/CDs

Care Facility Transitional

Behind in Payment?

Water

Child Care

Behind?

LIHEAP

Loans

SNAP

Spouse Salary

Interest

Other

2

SA/MH

Utilize as appropriate

Current Mental Health Services

Past Mental Health Services

Provider(s)

Mental Health Diagnosis

Meds related to mental health

Developmental Disability Yes

Diagnosis

Cognitive Impairment Yes

Diagnosis

No

No

Substance Abuse Yes

Drug(s) of Choice

No

Issues with Domestic Violence Yes

Areas of Need

No

Help w/ Medical Insurance or Payment source

Parenting Skills Counseling

Utilities Assistance Child Care

Substance Abuse

Domestic Abuse

Financial Assistance Employment

Medication Assistance

Dentist

Veterans

Elderly Issues

Education Issues

Maternal Child Health/ Child Development Issues

Food

Tobacco

Housing

Other

3

Referrals Made Information

Organization/ Agency Type of Service

Notes/Additional Information

Contact Name Release Signed

4

Appendix D

Example

Health Navigation Database

User Manual

Screen/Topic

Sign On

Clients/Current List & Search Function

Add Client

Edit Client

Client Referrals

Add Referral

Edit Referral

Appendix

Naming Rules Cheat Sheet

Notes/Documentation

Reports Available

Page

3

4 – 5

6 – 7

8

9

10 – 12

13-16

Table of Contents

18

19

20 - 21

2

Web address:

Username:

Password:

Click on “login”

Sign On

3

Clients (List & Search)

Login will take you to the clients screen. The last 20 clients, that had a referral contact, will be displayed in most recent date order.

4

Search – A search box is found on the upper right hand side of the screen. Search can be done utilizing first or last name and options that match become available as matching letters are being entered into the search box.

Navigating Through “Clients” Pages – Navigation keys to take you to additional “Clients” pages are located in the lower right hand corner of the page and include options of: first, previous, specific page numbers, next, and last.

View or Edit Client Information – Click directly on a client’s first or last name to view basic client demographic information.

View Client Referral Information – Click on the magnifying glass symbol next to a client’s name to view a list of referral(s) attached to that client.

Add Client – Click on “Add Client” at the top of the page to add a new client.

Merge Clients – THIS FUNCTION REQUIRES SPECIAL SECURITY; therefore not all users will be able to perform this function. A merge will be performed when a client has been entered twice due to error, use of alias, hyphenated name, etc.

5

Add Client

If a client is not currently in the system, a new client will be added collecting contact and basic demographic information.

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First Name – Enter first name. If client does not wish to provide first name enter “Anon”. If more than one client, not wishing to provide first AND last name, is received on the same day, the second client’s first name would be entered “Anon” with the number 2 following the name (ex. Anon-2).

Subsequent clients in this situation would be assigned the next chronological number. Refer to Appendix: “Naming Rules Cheat Sheet”

Last Name – Enter last name. If client provided first name but does notwish to provide last name enter “Anon” (ex. First Name = Maria; Last Name =

Anon). If client does not wish to provide first AND last name, enter date (ex. First Name = Anon; Last Name = 1/31/12). Refer to Appendix: “Naming

Rules Cheat Sheet”

Address – Two lines are allowed for street address. These fields are optional.

City – This field must be entered.

Zip code – Enter if known; this field is optional.

Phone – Enter if client wishes to provide. This field is optional.

Email – Enter if email is necessary to communicate with client. This field is optional.

Gender – This field must be selected (female/male). In the infrequent circumstance where gender is not apparent; or, someone does not wish to self identify, a gender must be assigned.

Race – This field is required and is a dropdown with choices (white, black, native American/native Alaskan, Hawaiian Islander/Pacific Islander, Asian, multi, unknown).

Ethnicity – This field is required and is a dropdown with choices (Latino, non-Latino)

Annual Income – This field is optional and should be entered WITHOUT $ sign, commas or cents (ex. 30500).

Household Size – This field is optional.

Federal Poverty Level – If both annual income and household size are entered, click on “Calculate” and the system will automatically calculate percent of poverty level.

Add/Cancel – After all information has been entered, click on “Add” to add the record to the system. If for some reason the record should not be added, click on “Cancel”. Attempting to leave the screen without choosing “Add” or “Cancel” will result in a pop up message “If you leave this page any unsaved changes will be discarded. Please confirm that is desired.” Two options are then provided “Confirm” or “Cancel” and one must be chosen.

Please note that not all of the above information may be available in the first contact with client but may be collected during a later contact. For example, income and household size may be provided during a later contact when assisting with application for a benefit. As information becomes

available, it is important that the information be updated via the “Edit” function.

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Edit Client

Access this screen via the “Clients” page by clicking on the first or last name of the client you wish to edit.

Edit necessary fields.

Save/Cancel – Select “Save” or “Cancel”. Attempting to leave the screen without choosing “Save” or “Cancel” will result in a pop up message “If you leave this page any unsaved changes will be discarded. Please confirm that is desired.” Two options are then provided “Confirm” or “Cancel” and one must be chosen.

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Client Referrals

Review Summary – To view a list of current or previous health navigation referral(s) for a specific client, select the client from “Clients” screen and click on magnifying glass symbol next to the client’s name.

Add Referral – To add a referral click on “Add Referral”.

Edit Referral – To edit (revise or add information), regarding a specific referral, click on the primary presenting issue to be edited (ex.

Parenting/Childcare).

View Referral Detail – To view referral detail, click on the primary presenting issue to be viewed (ex. Parenting/Childcare)..

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Add Referral

(Screen Section 1)

10

Add Referral

(Screen Section 2)

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Date Received – Select the date that the referral was received from the calendar provided. This is the date the phone call, fax or email came into our office.

Age Range – Select the age range from the drop down selection.

Date of First Contact – Select the date that contact was first made with the client from the calendar provided. Please note that you may choose a past date; but, not a future date.

Referral Source – Select “Tier 1” or “Tier 2” from the drop down selection. Tier 1 referrals are those received from a medical provider and will require an additional drop down selection. If the referring provider is not a drop down choice, select “Other”. Tier 2 referrals are those received from a nonmedical community partner or directly from the client or a family member; and, will require an additional drop down selection.

Follow-Up Date 1 – The date will automatically calculate and enter for two weeks from “Date of First Contact”. Checking in on client progress and

follow up reporting to the Tier 1 referral source is required. A report can be run based on this date for the purpose of tracking and timely follow up. In the event of a Tier 2 referral source, the user may choose to delete this date or leave the date for follow-up if the client’s situation warrants (this will be at the discretion of the Health Navigator).

Follow-Up Date 2 – In the event of a Tier 1 referral source, the date will automatically calculate and enter for four weeks from “Date of First Contact”.

Checking in on client progress and follow up reporting to the Tier 1 referral source is required. A report can be run based on this date for the purpose of tracking and timely follow up. In the event of a Tier 2 referral source, the user may choose to delete this date or leave the date for follow-up if the client’s situation warrants (this will be at the discretion of the Health Navigator).

Primary Presenting Issue – Select the client’s primary presenting issue from the drop down selection; ONLY ONE may be selected. Additional issues will be addressed under “Other Programs/Referrals”. However, if the client’s primary presenting issue is something other than “access to medical care”; but later in working with the client, “access to medical care” becomes an issue, an additional “Add Referral” page will need to be completed.

Program Referrals (Access to Medical Care) – If “Access to Medical Care” is selected as the primary presenting issue, the “Program Referrals “box will appear with a selection of programs/resources. Select ALL programs/resources to which the client is referred; multiple options may be selected. If the client is referred to a program/resource not specifically listed, select “Other”.

Other Programs/Referrals – Select ALL applicable programs/resources to which the client is referred; multiple options may be selected. If the client is referred to a program/resource not specifically listed, select “Other” and be sure to specify in “Notes” section.

Barriers to Accessing Services – Select ALL applicable barriers; multiple options may be selected. If no known barriers, select “None/Unknown”.

Notes – Use this space to briefly record the initial situation/contact with client. For example, “Recently divorced and lost job; and, has current medical and dental needs. Referred to free clinic and Venus for immediate needs; to Iowa Care if serious condition diagnosed and PHC for dental. Also provided

LIHEAP and food panty info.” For more information on notes/documentation refer to Appendix: “Health Navigation Notes/Documentation”.

Succeeding Contacts – This field will be used for future contacts with the client (see Edit Referral section of this manual). For more information on notes/documentation refer to Appendix: “Health Navigation Notes/Documentation”.

Add/Cancel – After all information has been entered, click on “Add” to add the referral record to the system. If for some reason the record should not be added, click on “Cancel”. Attempting to leave the screen without choosing “Add” or “Cancel” will result in a pop up message “If you leave this page any unsaved changes will be discarded. Please confirm that is desired.” Two options are then provided “Confirm” or “Cancel” and one must be chosen.

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Edit Referral

(Screen Section 1)

13

Edit Referral

(Screen Section 2)

14

Edit Referral/Succeeding Contacts

(Screen Section 3)

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When to Utilize the Edit Function

Correction or Addition of Information (Screen Sections 1 & 2)

Referrals should only be edited for correction of information or addition of information (ex. additional referrals provided, additional barriers to access, addition or correction/clarification in notes, etc.). The editing function should not be used to delete information. Edit necessary fields.

Save/Cancel – After necessary fields have been edited, click on “Save” or “Cancel”. Attempting to leave the screen without choosing “Save” or “Cancel” will result in a pop up message “If you leave this page any unsaved changes will be discarded. Please confirm that is desired.” Two options are then provided “Confirm” or “Cancel” and one must be chosen.

Succeeding Contact(s) (Screen Section 3)

After the initial contact, all succeeding contact will be entered in this section. Do not add succeeding contact(s) in the general “Notes” section.

Add a Contact

Scroll to the “Succeeding Contacts” area of the screen. Click on “New” and an “Edit Form” box will pop up.

Date of Contact - Select the date that contact was made with the client from the calendar provided. Please note that you may choose a past date; but, not a future date.

Succeeding Contact(s) Note - Enter brief information in this area. Should the original user be out of the office, this information should be enough to guide someone else in the event of a future client contact. For more information on notes/documentation refer to Appendix: “Health Navigation

Notes/Documentation”.

Update/Cancel – After all information has been entered, click on “Update” to add the contact to the system. If for some reason the contact should not be added, click on “Cancel”. Once “Update” is selected, you will be taken back to the “Update Referral” screen.

Save/Cancel – Before leaving the “Update Referral” screen, “Save” or “Cancel” must be selected. Attempting to leave the screen without choosing

“Save” or “Cancel” will result in a pop up message “If you leave this page any unsaved changes will be discarded. Please confirm that is desired.” Two options are then provided “Confirm” or “Cancel” and one must be chosen.

Edit a Contact

Scroll to the “Succeeding Contacts” area of the screen. Click on “Edit” next to the contact to be revised and an “Edit Form” box will pop up. The editing

function should not be used to delete information. Edit the date and/or note. For more information on notes/documentation refer to Appendix:

“Health Navigation Notes/Documentation”.

Update/Cancel - After all information has been revised, click on “Update” to add the contact to the system. If for some reason the contact should not be added, click on “Cancel”. Once “Update” is selected, you will be taken back to the “Update Referral” screen.

Save/Cancel – Before leaving the “Update Referral” screen, “Save” or “Cancel” must be selected. Attempting to leave the screen without choosing

“Save” or “Cancel” will result in a pop up message “If you leave this page any unsaved changes will be discarded. Please confirm that is desired.” Two options are then provided “Confirm” or “Cancel” and one must be chosen.

Please note - after the client’s referral has been entered in the system, all succeeding contact for that specific referral should be entered utilizing the

edit function. Please note - if 60 days has passed since the referral’s date of first contact, a new referral record will be required.

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Appendix

17

Health Navigation Database Naming Rules Cheat Sheet

Info Provided

First & Last Name

First Name Only

First Name

First Name as provided

First Name as provided

Last Name Only

No name provided

Anon

Anon

2nd No name provided today Anon-2

Last Name

Last Name as provided

Anon

Last Name as provided

Today's Date

Today's Date

Examples:

John Smith calls – Enter John in First Name and Smith in Last Name

Esther calls – Enter Esther in First Name and Anon in Last Name

Mrs. Howard calls – Enter Anon in First Name and Howard in Last Name

A man calls on 3/19/2012 and does not give his name – Enter Anon in First Name and 3/19/2012 in Last Name

A different man calls on 3/19/2012 and does not give his name – Enter Anon-2 in First Name and 3/19/2012 in Last Name

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Health Navigation Notes/Documentation

Health Navigation notes are critical for documentation of the services provided to each client. Health Navigation notes should be clear, concise, brief, accurate, timely and factual. Health Navigation notes should describe the situation/need and services provided by Health Navigator; and, document referrals made and client’s progress.

Utilize the “Notes” section of the referral page in the Health Navigation database to record the initial situation/contact with the client. Each additional contact with, or on behalf, of the client must be documented in the “Succeeding Contacts” section.

Make every attempt to enter Health Navigation notes during the interaction or immediately following the interaction; make sure it is recorded on the system under the date it actually occurred. Health Navigation notes must be entered within one business day of the contact.

At the beginning of the Health Navigation note, state the mode of contact first: telephone (TC), office visit (OV), home visit (HV), collateral contact (CC). At the end of the note, conclude with your initials.

When writing a Health Navigation note, don’t write a volume; but, give enough detail that if you are out of the office tomorrow, another staff can assist the client with minimal duplication of effort (include contact names and telephone numbers of those you are working with)

Do not record client statements as facts. Utilize “client states” or “client reports”

Do not assign psychological terms to a client such as “bipolar” “post-traumatic stress disorder”, etc unless it is part of the medical record.

Avoid diagnoses, clichés, street jargon, stereotypes and prejudices.

Utilize the word “client” and any other related persons by their relationship to the client followed by their name the first time used (ex.

Client states he is living with his brother, Todd. Brother is paying housing expenses.)

Utilize the abbreviation HN for yourself

If the contact is with someone other than the client and there is no release in the file, note there was no release and you did not provide the caller with info

If the Health Navigation note documents a potentially serious problem such as extreme depression or client making statements regarding suicide or threats to others, make sure you follow it up with the action you took and immediately consult with your supervisor

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Reports Available

Creating reports requires special security; therefore, not all users will be able to perform this function.

Referral Source by Client – Timeframe must be selected and will be based on “Date Received” from Referral Screen. The report will show individual Tier

1 and Tier 2 clients broken down by referral source. Please note, there could be duplicate clients from various referral sources if the timeframe selected is more than a 60 day period.

Unique Clients Served – Timeframe must be selected and will be based on “Date of First Contact” and/or “Succeeding Contacts Contact Date” from

Referral Screen. This will provide a list of unduplicated clients.

Tier 1 Follow-up Dates – Timeframe must be selected and will be based on “Follow-up Date 1” or “Follow-up Date 2” falling within the range.

Tier 2 Optional Follow-up Dates - Timeframe must be selected and will be based on “Follow-up Date 1” or “Follow-up Date 2” falling within the range.

All Client Contacts/First Contact

Timeframe must be selected and will be based on “Date of First Contact” from Referral Screen. This can be added with All Client Contacts/Succeeding Contacts report to find the total number of client contacts during a specific period. In addition, the total number of contacts can be divided by Unique Clients Served report for the same timeframe to find the average number of contacts per client.

All Client Contacts/Succeeding Contacts

Timeframe must be selected and will be based on “Succeeding Contacts Contact Date” from Referral

Screen. This can be added with All Client Contacts/First Contact report to find the total number of client contacts during a specific period. In addition, the total number of contacts can be divided by Unique Clients Served report for the same timeframe to find the average number of contacts per client.

Referral by Type/Access to Care

Timeframe must be selected and will be based on “Date of First Contact” and/or “Succeeding Contacts Contact

Date” from Referral Screen. This can be added with Referrals by Type/Other report to find the total number of client referrals during a specific period.

In addition, the total number of referrals can be divided by Unique Clients Served report for the same timeframe to find the average number of referrals per client.

Referral by Type/Other

Timeframe must be selected and will be based on “Date of First Contact” and/or “Succeeding Contacts Contact Date” from

Referral Screen. This can be added with Referrals by Type/Access to Care report to find the total number of client referrals during a specific period. In addition, the total number of referrals can be divided by Unique Clients Served report for the same timeframe to find the average number of referrals per client.

Demographics -

Timeframe must be selected and will be based on “Date of First Contact” and/or “Succeeding Contacts Contact Date” from Referral

Screen. This will provide an unduplicated count. Each demographic listed below must be run separately.

20

Gender

Age

Race

Ethnicity

City

FPL (Because income is an optional field, information will only be provided on clients who have income and family size entered.)

Primary Presenting Issue by Type – Timeframe must be selected and will be based on “Date of First Contact”. This report will provide a total for each type of issue.

Barriers by Type – Timeframe must be selected and will be based on “Date of First Contact” and/or “Succeeding Contacts Contact Date” from Referral

Screen. This report will provide a total for each type of barrier.

Contacts with Notes – This report prints all notes (both initial and succeeding) on a specific client. This is utilized for reporting back to Tier 1 medical providers.

21

Appendix E

Sample Health Navigation Policy

Status: Approved

Issue Date: xx.xx.xx

The goal of Health Navigation Coordination is to improve comprehensive, coordination and continuity of care for Dallas County residents. The program supports medical providers and agencies in Dallas County through facilitation and follow-up of patient/client referrals to community resources. The program is available to any Dallas County resident with priority given to patients who are referred by a medical provider.

References

The references listed below are resources that may help you understand and complete this procedure. If you need help locating the noted references, see your supervisor or manager.

NUMBER

1 Iowa Public Health Standards

DESCRIPTION

Exhibits

The exhibits listed below are a compilation of sample forms, screen printouts, etc. that provide a useful visual guide when performing a task in a specific program.

NUMBER

1

2

3

4

5

DESCRIPTION

Health Navigation Clinic Referral Tool

Health Navigation Screening Tool

Health Navigation Database User Manual

Health Navigation Postcard

Health Navigation Call Record

Procedure:

STEP

1

2

3

ACTION

The Health Navigator will promote the program to community agencies; and, the Public Health Nurse Clinician will promote the program to medical providers via face to face contact and distribution of written materials. Medical providers will be considered Tier 1 referrals (patients) and all others will be Tier

2 referrals (clients).

Tier 1 providers will obtain a release of information from the patient authorizing exchange of information between the provider and the Health Navigator. For

Tier 1 and 2 referrals, the Health Navigator will obtain appropriate releases as necessary.

Tier 1 providers will complete a brief

“Clinic Referral” including: clinic name, referral date, patient name, date of birth, and reason for referral. The referral will be faxed to the Public Health Nurse Clinician for review and tracking

4

5

6

7

8

9 purposes. The Public Health Nurse Clinician will provide the referral to the

Health Navigator along with additional medical information if necessary.

The Health Navigator will contact the patient/client being referred within three business days.

The Health Navigator will meet with the patient/client face to face or via phone and complete a

“Health Navigation Screening” to obtain pertinent information and determine potential needs and resources available. The Health Navigator along with the patient/client will determine the amount of information collected.

The Health Navigator will document all referrals made and/or follow-up action in the Health Navigation database. The Public Health Nurse Clinician will review the database information, make any revisions necessary, and provide the information to the Tier 1 provider.

The Health Navigator will contact Tier 1 patients at a minimum two weeks and four weeks from the original date of screening to check on progress/need for further assistance. Additional contact may be made as deemed necessary in accordance with specific circumstances. Tier 2 patients will be contacted as needed.

The Public Health Nurse Clinician will report each patient contact/progress to

Tier 1 providers by either fax or mail.

If after 4 weeks the Health Navigator has been unable to reach the patient/client, the patient/client has declined assistance, or it appears the patient/client is unwilling to take the steps recommended, the Health Navigator will consider the patient/client’s file closed and report this action to the Public

Health Nurse Clinician who will notify the Tier 1 provider via fax or mail.

10 For tracking and reporting purposes, the Health Navigator will enter each patient/client into the Health Navigation Database at referral and continually update as actions/contacts/referrals are made.

11 After the end of each month, the Community Health Coordinator and Office

Manager will run Health Navigation Database reports to monitor and report

Health Navigation activity.

12 All Tier 1 referrals will be monitored by the Public Health Nurse Clinician, in addition to the Health Navigator, on an ongoing basis. In the event of unresolved Tier 1 issues/cases, the Public Health Nurse Clinician will work with the Health Navigator and medical provider to assist with progress or conclusion of the file.

Appendix F

SAMPLE

Appendix G

Report Examples

Primary Presenting Issue by Type

3/1/13 - 3/31/13

Primary Issue Type

Access to Medical Care

Financial

Food

Number Percent

38

4

2

73%

8%

4%

Housing

Legal

Parenting/Childcare

Sub Abuse/Mental Health

Transportation

Total

1

2

1

2

2

52

2%

4%

2%

4%

4%

Referrals Provided for Access to Care

3/1/13 - 3/31/13

Program/Referral for Access to Medical Care Number Percent

Care for Yourself 19 24%

Clinic Assistance hawk-i

7

1

9%

1%

Hospital Assistance

Iowa Care

Medicaid Programs (all incl waivers)

Medication Assistance Voucher/Programs

Free Clinic

Other

Total

6

11

4

6

15

11

80

8%

14%

5%

8%

19%

14%

Other Program/Referrals Provided

3/1/13 - 3/31/13

Program Referral Number Percent

Elderly Issue

Employment

1

2

2%

4%

Financial

Food

Housing

Legal

Medical General Info

Parenting/Childcare

Sub Abuse/Mental Health

Utilities

Other

Total

14

6

3

3

1

5

7

7

8

57

25%

11%

5%

5%

2%

9%

12%

12%

14%

Barriers by Type

3/1/13 - 3/31/13

Service Barrier

Availability Location/Hours

Childcare

Number Percent

4

2

5%

2%

Cognitive

Income

Language

None/Unknown

Transportation

1

34

23

9

8

1%

42%

28%

11%

10%

Total

City

Adel

DeSoto

Minburn

Perry

City of Residence

3/1/13 - 3/31/13

Number Percent

10 19%

1

2

25

2%

4%

48%

Redfield

Van Meter

Waukee

Woodward

Total

8

2

3

1

52

6%

2%

15%

4%

Tier 1 Follow up Dates

Run Date 8/26/13

Client Name F/U 1 F/U 2

XXXXXXXXXX 8/28/2013

XXXXXXXXXX 9/2/2013 9/16/2013

XXXXXXXXXX 9/5/2013 9/19/2013

XXXXXXXXXX 9/9/2013 9/23/2013

XXXXXXXXXX 9/9/2013 9/23/2013

Tier 1

Source:

Referral Source by Client

3/1/13 - 3/15/13

Client Name

XXXXXXX

Mercy Perry

Number Referrals

XXXXXXX

Source:

Subtotal

Client Name

1

Unity Point Waukee

Number Referrals

1

2

XXXXXXX

XXXXXXX

XXXXXXX

Subtotal

Source:

Client Name

XXXXXXX

XXXXXXX

1

3

1

1

XXXXXXX

XXXXXXX

XXXXXXX

Source:

Subtotal

Total Tier 1

Tier 2

Client Name

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

Subtotal

Free Clinic Waukee

Number Referrals

10

Community Partner

Number Referrals

1

1

1

1

1

1

5

1

4

1

1

Self/Family

Number Referrals

Source:

Client Name

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

Subtotal

Total Tier 2

Total Tier 1 & 2

5

9

19

1

1

1

1

1

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