Making Hospital Homecoming More Hospitable - ReServe's Health Navigator Program

ReServe has begun testing its Health Navigator program at two New York City hospitals aimed at creating a vital link between staff members and patients who might be frail or isolated or need assistance after discharge from the hospital. “In a nutshell, it enables us to stay in touch and minimize emergency situations,” Patrick Inniss, director of social work at St. Luke’s Hospital uptown, said. “Too often patients lose contact because no one is investigating how they are managing in the community.”

Navigators will be the “eyes and ears” for hospital social workers and will be advocates for clients. “The idea is to identify those who lack sufficient social support to navigate the health care system, which in this day and age is more and more difficult,” Beatrice Maloney said. She is the supervisor of geriatric services in the department of social work and home care at Beth Israel Medical Center downtown. She and Inniss are the top go-to’s for Laurie Hyman, ReServe’s Health Navigator Coordinator,who developed the program with Jess Geevarghese, ReServe’s program officer who focuses much of her attention on elder-to-elder projects.

There are many services for the infirm and elderly, but Claire Haaga Altman, executive director of ReServe, said that Health Navigators is unique in that it “is a unique opportunity for ReServe and our hospital partners, St. Luke’s-Roosevelt and Beth Israel, to test the proposition that if assistance is provided to individuals discharged from hospitals to help them get the concrete services they need, they can remain in their own homes longer and avoid unnecessary hospital stays and emergency room visits.”

Another variation on health navigation in ReServe’s portfolio of projects is the Patient Navigator Project at NY Presbyterian’s Allen Pavilion where two ReServists, Chinmayee Chakrabarty and Maria Hermans, call patients who have been discharged the previous day to make sure they are managing at home well. This project has significant potential for growth and is poised to be an important link in the discharge process at NY Presbyterian.

Henriette Arzewski and Karol Stonger are assigned to St. Luke’s, and Judy Capel and Natalie Millner are the first team at Beth Israel. Both hospitals are part of the Continuum Health Partners Inc. Volunteers will visit client homes once a week and follow up with phone calls, looking for signs of physical, financial or emotional distress or well-being and assessing any safety issues. “Visits in the home might minimize emergency situations by providing assistance, helping to apply for benefits, making clinic appointments, preventing isolation and providing emotional support,” Inniss said.

The Health Navigators’ pilot project is funded by Continuum Health Partners, the MetLife Foundation, the Stella and Charles Guttman Foundation and the Max and Victoria Dreyfus Foundation. The Fan Fox Samuels Foundation provides wrap around support for ReServe’s Elder to Elder Projects.