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Patient navigators address barriers to health care

October 11, 2017
by Jenny Blair

Priscilla Wang, M.D. ’17, recalls a frightening moment at her patient’s house. She watched in dismay as the man, who had disabilities, clung for balance to flimsy towel bars in his bathroom.

“It made me really upset. … He could easily fall; he could break his hip because of this unsafe arrangement,” Wang recalled. Yet his health insurance did not make funds available to help prevent a potentially catastrophic and expensive injury.

“This experience was really eye-opening, in that it made me realize that it’s in the day-to-day settings that health is determined,” she said.

The home visit took place as part of a pilot patient navigators program Wang co-founded in 2016. The Patient Navigator Program (PNP) or Yale Patient Navigator Program pairs nine teams of senior and junior medical students with patients from Yale’s primary care clinics who faced serious social barriers to health. Supported by lectures from faculty, social workers and New Haven outreach workers and through visits with patients, the students learned to go beyond brief clinical encounters, listen to and learn what patients are up against, and provide meaningful support.

“Many of the problems we address in the hospital are not necessarily biological in their root causes. There are many ways in which medical students can meaningfully address these deeper issues,” said Wang, who worked on the project before her graduation in May.

Indeed, the quest for better health asks a lot of patients—literacy, transportation, disposable income. Being unable to read or travel to the office or pay for parking can derail even the best medical advice. Many people risk being fired if they miss work for a doctor’s appointment. Others contend with domestic abuse or the criminal justice system. Cars break down, buses don’t serve the neighborhood or don’t arrive, and missed appointments ensue, which can lead providers to discharge patients from the clinic. People may lack information about healthful living or support for quitting tobacco, or are confused by their doctors’ instructions. Some people simply mistrust the health care system. Such problems don’t get much space in formal med school curricula.

So the student navigators helped their patients make sense of multiple bottles of medicine. They connected people to food assistance and discounted transportation, and low-income housing. One man lacked a phone, so his student team signed him up for a free Obama Phone (cell phones for low-income Americans).

Nisha Dalvie, then in her first year of medical school, accompanied her patient, a man in his 50s, to the courthouse for help with housing, to his physical therapy, to the housing authority. Not only did he contend with diabetes and a condition causing muscular weakness, but he also had low literacy. He had trouble reading forms and medication instructions, but he didn’t want to attend a nearby literacy program and reveal his difficulty to people he’d known since childhood. Dalvie and her teammate, fourth-year medical student Sean Maroongroge, helped him obtain tutoring in another part of town where he could study in anonymity.

“It was great to see how many things were available for him by basically just googling things and emailing people, trying to figure out what we could do,” Dalvie said. “There’s so much out there, and you really don't learn it in medical school.”

The navigators program is an outgrowth of Students for a Better Healthcare System, which M.D./Ph.D. student Lorenzo Sewanan and several other students founded in 2012 to help educate New Haven residents about the Affordable Care Act. During teach-ins they conducted in schools, in churches, and at the School of Medicine, the students picked up on problems that go beyond health insurance. “Even though more and more people were having ‘access’ to health care or at least health care insurance,” Sewanan said, specifying the quotation marks, “it didn’t necessarily mean they were getting to receive the best care, or getting the benefits of that care.”

The difficult world some patients inhabit was uncharted territory for students like Dalvie, who said she had a privileged upbringing.

“There’s a lot of tension in this city, I feel, between people who are impoverished and the students, who are most often not,” Dalvie said. “I hadn’t really seen it like that in any other place where I’d been, where those who didn't have as much were so in the forefront of the city. … We got to see how all of these issues extend beyond the clinic.”

Co-founded by Wang, Sewanan, Eamon Duffy, Julianna Berk-Krauss and Matt Meizlish, and supported by several physician advisors, including Pinar Oray-Schrom, M.D., HS ‘02, assistant professor of medicine (general medicine), the program completed its pilot year to rave reviews from students who participated. One student called it “one of the most formative experiences of my Yale career.” Another wrote, “There is nothing at Yale more patient-centered than this.”

Patient navigation has its roots in a program started by Harold P. Freeman, M.D., in Harlem in 1990 to assist primarily the poor and uninsured to access cancer care; it grew to become the Harold P. Freeman Patient Navigation Institute, which now trains navigators all over the country. New Haven’s Gateway Community College also offers training.

Sewanan says the student program was also inspired by “hotspotting,” an approach pioneered by Jeffrey Brenner, M.D., in Camden, N.J., in which teams of providers work directly with high-risk patients who use the most health care services. The teams address social needs as well as smoothing paths through the health care system, with a resulting drop in the need for hospital services.

For Wang, learning more about her patient’s life was such a powerful experience that she switched career plans while on the residency interview trail. Wang abandoned her plans to train in categorical internal medicine, instead landing a last-minute spot in the primary care residency at Harvard’s Brigham and Women’s Hospital in Boston—a change of heart for someone who began medical school interested in orthopaedic surgery.

“It’s a really humbling, a really powerful experience to step into a patient's home and see the challenges that they are living with on a day-to-day basis,” she said.

This year, navigators are working on expanding their reach to include patients with diabetes and mental health issues.

With the Affordable Care Act and social services under threat in the current political climate, patients and physicians face ever-stiffer headwinds. Still, Sewanan believes that patients and medical students possess the power to act in meaningful ways. “If we can’t achieve what we want at the policy level,” Sewanan said, “I think there’s still a lot that can be done at the personal, individual level.”

Correction: An earlier version of this article included a sentence that mischaracterized the PNP as being an umbrella organization for other similarly patient-oriented student-led organizations in the Greater New Haven area.

Submitted by Adrian Bonenberger on October 11, 2017