Enhancing Community Health Through Patient Navigation, Advocacy and Social Support

Summary

Some patients who have multiple long-term health conditions have significant challenges accessing needed services despite available primary care and social services resources. Patient navigation programs may help those with complex health conditions improve their care and outcomes and if delivered by community health navigators (CHNs) who have close community ties, these programs have the potential to reduce barriers to care and increase access to coordinated, person-centred care. The ENCOMPASS program aims to improve the care and health outcomes for high-risk patients by linking patients with chronic disease with a CHN to help them navigate the health system, facilitate communication between patients and providers, improve patients' understanding of their conditions and treatment plans, and support patients in their self-management. In Canada, patient navigation programs have not been well studied or broadly implemented in patients with chronic disease, making a comprehensive evaluation of ENCOMPASS important. This program has great potential to improve care for patients with chronic diseases in primary care.

Conditions

• Hypertension
• Diabetes Mellitus, Type 2
• Chronic Kidney Diseases
• Ischemic Heart Disease
• Congestive Heart Failure
• Chronic Obstructive Pulmonary Disease
• Asthma

Interventions

BEHAVIORAL

ENCOMPASS Intervention

Patients will be matched to a CHN who will conduct a needs assessment to determine the frequency of meetings. A CHN may perform any of the following: providing information to a patient's health care provider, translation, advocating for the patient, connecting the patient with resources (i.e., social, financial, insurance), helping patients set health related goals, liaising with a patient's employer, facilitating health care referrals and appointments, monitoring appointments, and facilitating transportation to appointments. These activities may require the CHN to be physically present at appointments or have direct contact with the patient's health care provider. Goal setting and support will be provided in person or over the telephone using motivational interviewing principles

Sponsors & Collaborators

• Alberta Innovates Health Solutions

  collaborator OTHER

• Canadian Diabetes Association

  collaborator OTHER

• University of Calgary

  lead OTHER

Principal Investigators

• Kerry A McBrien, MD, MPH · University of Calgary

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

SINGLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2018-06-08

Primary Completion

2023-03-03

Completion

2024-03-03

Countries

• Canada

Study Locations