A qualitative study exploring a community health navigator intervention for patients with chronic and complex care needs transitioning from hospital to home

Background: Community Health Navigators (CHNs) can promote healthcare access and care coordination. However, little is known about the experiences of stakeholders when CHNs are embedded within a multidisciplinary care team setting. The CHN role aimed to improve the transition from acute care to home for patients with chronic conditions, through linkage to general practitioners, other professional follow-up, and social and community supports. Methods: Three CHNs were employed and located in an Aged Health, Rehabilitation and Chronic Care outreach team in Sydney, Australia. This qualitative study aimed to explore the perceptions of patients, healthcare professionals (HCPs), and CHNs about the support provided, and to determine what factors supported or impeded the CHN role in this setting to inform implementation in the Australian context. Results: Twenty semi-structured interviews with twelve patients, five HCPs and three CHNs were analysed inductively using interpretive thematic analysis. Three key themes were constructed: operationalising CHN integration into the team setting; contributions to support the needs of patients post-hospitalisation; and, experiencing the emerging navigation role. Timely emotional, informational, and practical support provided during the transition period were highlighted. The healthcare team viewed the CHN as valuable to support patients non-clinical needs and patient management. The interface between the clinical focus of the team and the non-clinical nature of the role was challenging. Supportive supervision was essential to support knowledge, problem solving, and to promote acceptance within the team. Conclusions: The findings suggest CHN roles can offer a ‘safety net’ for transitioning patients. Integrating this role within a complex clinical care setting requires time, organisational commitment, and policy and guidelines to address the interface with other professional healthcare roles. Promotion to patients, clinicians, and other service providers is required to improve awareness of the CHN role. Trial registration number: Trial registration number: ACTRN12622000659707. Date of registration: 5 May 2022.