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Steering Them Through the Maze
Patient navigators help the underserved decode health care’s bureaucracy.

Harry Koffenberger, vice president of Corporate Security, in the department's command center. At work in the background are protective services officers Darlene Fairley (left) and Tanaya Hitt.
Julie Horst (foreground), waiting beside her red Nissan, and Dawna McGlynn (background) both trained as social workers before becoming patient navigators.

Julie Horst feels sporty behind the wheel of the 2008, candy-apple red, Nissan hatchback. With a Hopkins badge around her neck and a heart patient belted in beside her, she zips to a community doctor, or to a pharmacy, or maybe to an appointment with a Hopkins cardiologist. Horst isn’t just navigating the streets of Baltimore. She’s helping underinsured and uninsured cardiac patients cut through the red tape and hidden resources of health care.

The red “taxi” is a vital part of a new study looking to see if patient navigators like Horst can improve outcomes for elderly and poor populations, as well as those with inadequate insurance who can’t afford high co-pays or expensive medications. Overall, that group suffers greater complications and more deaths from coronary artery disease.

“You cannot begin to imagine the horrible scope of this problem and the fact that people die every day simply because they can't afford care or medicines,” says medical researcher Diane Becker, principal investigator of the study. “Bureaucratic systems are very difficult to figure out. They sometimes indiscriminately deny benefits, and often people give up and just stop their medicines if they are too expensive.”

Patient navigators here have already steered cancer patients to better outcomes by educating low-income women about the importance of early diagnosis and treatment. Becker’s study goes the extra mile to determine if patients can achieve sustainable results by removing barriers, such as insufficient finances or access to care.

Horst, who works with a second navigator, Dawna McGlynn, assesses eligible patients, enrolls them in the study and manages their progress. “If the patient doesn’t have primary care, I’m trying to get them an available doctor in the community,” she says. “If they need medication, I’m trying to find them the best place to get their prescriptions.” Sometimes that entails educating doctors to use comparable drugs or generics that can cost a quarter of name brands.

Patient navigators are hybrids. Part social worker, part case manager, part health educator, part community health worker and part nurse, “they teach people how to advocate for themselves and figure out roadblocks in the system,” says Becker. A previous pilot study showed that they can make a marked improvement in reducing the rate of subsequent heart problems.

Patients are enrolled in the study after treatment at Hopkins Hospital or Hopkins Bayview Medical Center for a heart attack, angioplasty, bypass surgery or medically treated angina and assigned either a navigator or other post-hospital assistance. Becker and her colleagues will analyze whether navigators are on the right road by comparing behavioral, biological and vascular results. Specifically, they will evaluate a patient’s compliance with drug therapies, measure LDL cholesterol and blood pressure levels and compare arterial blood flow at different times during the study.

Because coronary artery disease is one of the most common conditions in the United States, and because taking key medications can reduce rates of second events, or even death, it was important to figure out the role of navigators in heart health, says Becker, a passionate advocate for underserved communities.

The study is backed by a 2005 federal act promising $23 million in funding for the development and operation of patient navigator services for underserved populations, including Native Americans, African Americans, Latino communities and old-order Amish. Becker’s 5-year study is funded by the National Institute of Nursing Research and builds on the work of fellow medical researcher Jay Vaidya.

Vaidya has tested the use of patient navigators in the delivery of statins (lipid-lowering and anti-inflammatory medications) to some of the poorest heart patients. While those results are pending, they indicate that researchers are on the right track.

Crucial to the study is a wide team that includes William Baumgartner, cardiac surgery director at Hopkins, Myron Weisfeldt, chairman of the Department of Medicine, Karen Haller, vice president for Nursing and Patient Care Services, and Nisha Chandra-Strobos, chief of the Division of Cardiology at Hopkins Bayview Medical Center.

“The navigator protocol is a way to help these people get the care they need and deserve,” says Chandra-Strobos. “It will clearly help patients, and help define how our present system of care can be improved for those who need it most.”

Michele McFarland



Johns Hopkins Medicine

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