Enhancing Care Integration and Accessibility through Patient Navigation

Background: Individuals with complex care needs (CCNs) require more health and social care services than the average population. These individuals have better outcomes if they have access to integrated services across settings and sectors. One solution to address the multifaceted care needs of this population is patient navigation (PN). This model is increasingly being used across North America and abroad and is defined as a patient-centred approach intended to proactively guide, support, and orient patients through health and social care systems, matching patientsunmet needs to appropriate resources. Our research team at the Centre for Research in Integrated Care (CRIC) has developed, implemented, and evaluated PN programs in New Brunswick (NB) for two populations commonly experiencing complex care needs: children/youth with chronic and/or complex conditions and older adults living with dementia. Approach: At CRIC, we use a patient-oriented research approach, which engages patient partners throughout the entire research process. For example, when implementing and evaluating our PN programs, we did so in partnership with patient and family advisory councils. NaviCare/SoinsNavi was a research-based PN program for children/youth with complex care needs (CCNs), their families, and the care team. One bilingual navigator and one lay navigator were housed at an academic institution and provided in-person and virtual navigation services to participants across NB. Navigating Dementia NB/Naviguer la dmence NB was a research project that piloted a PN program for people with dementia (PWD), their care partners, and the care team. Six patient navigators (4 anglophone and 2 francophone) were embedded in preexisting primary care clinics/health centres in urban and rural settings across NB. Results: NaviCare/SoinsNavi served 62 families and 42 care providers between January 207 and May 2020. Navigating Dementia NB/ Naviguer la dmence NB served 50 participants between July 2022 and July 2023. Interviews with caregiver clients from both PN programs highlighted that caregivers frequently reported feeling overwhelmed and isolated. However, patient navigation offered a solution to meet patient and caregiver needs by promoting more convenient and integrated care and enhancing access to education, support, and resources. Additionally, patient navigators delivered crucial emotional support to both patients and caregivers. These results support that PN is a flexible model of care and can be easily adapted to different populations and settings to promote positive experiences with health and social care systems and promote person-centred, integrated care. Implications: Next steps involve developing, implementing, and evaluating a PN program specifically tailored for youth with addictions and mental health needs, identified as a priority population in New Brunswick. CRIC ultimate goal is to enhance the experiences of individuals with complex care needs (CCN), along with their care partners and providers, within health and social care systems. By improving communication pathways and fostering better integration of care, we aim to create more cohesive and supportive care environments, thereby promoting more positive health outcomes for this vulnerable group.