The Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review Protocol

The Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review Protocol Abstract: Introduction: Patient navigation is a model of care that aims to reduce the complexity of navigating health, education, and social services across continuums of care and care settings. Worldwide, patient navigation is increasingly being used to improve healthcare delivery for adults with complex needs. Existing scoping reviews on patient navigation have excluded grey literature, not focused on adults with complex needs population or exclusively focused on primary care settings. Similarly, existing reviews have not considered the role of caregivers within patient navigation programs. In this paper, we outline our scoping review protocol to systematically review published and unpublished literature specific implemented patient navigation programs for adults with complex needs across all settings. Specifically, the protocol will aim to examine the literature describing implementation of patient navigation interventions and the characteristics and outcomes of the programs. Methods and analysis: Arksey and O’Malley’s scoping review methodology framework and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses extension for Scoping Reviews Checklist will guide the conduct of this scoping review. This scoping review will consist of published and grey literature for adults with complex needs patient navigation programs. Comprehensive searches of relevant electronic databases (e.g., MEDLINE, EMBASE) will be used to search for academic literature. To search for grey literature, systematic Google searches will be conducted. A review of websites of healthcare provider organisations (e.g., hospitals) will also be used to identify relevant material. We will review the reference lists of included materials to identify other literature appropriate for inclusion. Two reviewers will pilot-test the screening criteria and data abstraction form. They will then screen all citations, full articles and abstract data in duplicate independently. The Consolidated Framework for Implementation Research will serve as the theoretical framework during analysis. The results of the scoping review will be synthesised descriptively and thematically. Specifically, we will report on 1) when and how programs are developed and implemented 2) the content of programs and how these changes to meet the needs of patients and families and 3) the reported impact of these programs on patient and caregiver outcomes. Additional common themes amongst the program may also be reported on. Ethics and dissemination: This scoping review will synthesise the information around the implementation of existing patient navigation programs and their characteristics and outcomes as described in the literature. As this is a scoping review ethics approval is not indicated. Findings from this review will be useful to implementation scientists and health service researchers by identifying gaps in existing programs and evidence and for highlighting implementation strategies for adapting similar patient navigation interventions applicable to multiple care settings. The results will be disseminated through a peer-reviewed publication, conference presentations and a stakeholder meeting at a large urban hospital in Toronto. Strengths and Limitations of this Study • To the best of our knowledge this will be the first report on adult navigation programs that reflect the implementation and uniqueness of each program. • This review is guided by well-known methodological and theoretical frameworks. • This review includes a comprehensive literature search including grey literature. • We will use two independent investigators for all phases of the review. • We will only be including English-language articles published since 1990. Introduction: The world’s population is aging(1), and we are now seeing more adults living with chronic diseases (2). Adults are more likely than younger individuals to suffer from poor health and chronic conditions. Consequently, adults (defined as those 26 years and older) with complex needs (defined as adults aged 26 years and older with mixed mental, physical, cognitive, and social needs) use more healthcare services. To meet adults’ varying health and social care needs, many elements of the healthcare continuum are utilized, including emergency, acute, rehabilitation, community, and long-term care. An extensive body of literature shows that many adults with complex needs have difficulty accessing healthcare services and navigating the healthcare system, particularly following a hospital discharge (3-6). As a result of inadequate discharge and transitional planning, many patients face adverse outcomes, including morbidity and rehospitalization (7-11) . In an effort to people navigate and access health services across the care continuum, patient navigation has been proposed as an innovative intervention to address known barriers to obtaining care and achieve optimal health outcomes. Patient navigation programs originally began in cancer care but has expanded to be applied to other disease or populations (12-14) . However, there is little consensus about what constitutes patient navigation services (14), and there is little information on the efficacy of patient navigation in improving patient outcomes (13, 15). A recent review highlights that few studies assess patient experience, clinical outcomes or costs within patient navigation programs (16). In addition to supporting adults with complex needs, supporting family caregivers also remains a priority within healthcare policy. In Canada alone, eight million individuals identify as a family caregiver (friend, family or neighbour) to an individual with a disability, chronic condition or problems associated with aging (17). Family caregivers are often essential in helping adults navigate elements of the healthcare continuum (18-24). To assist them in their caregiving roles, caregivers have advocated for increased access to resources and system navigators (25). Unfortunately, there is currently little known about how patient navigation programs include the role of family caregivers in their planning, implementation and intended outcomes. This information is needed for stakeholders who plan to develop family-centred patient navigation models of care for adults with complex needs. Little is known about processes that facilitate or impede implementation of patient navigation programs. To effectively implement interventions to improve patient care into the local context barriers and facilitators to program implementation need to be explored (26). The field of implementation science lends theoretical frameworks that can inform the exploration of contextual factors that influence program development and implementation (27). The Consolidated Framework for Implementation Research (CFIR), identifies organizational and system level factors associated with program implementation (26). In the context of patient navigation, there is a wide variation in the design and implementation of existing patient navigator programs (16). No scoping review to date has summarized the characteristics of existing programs nor the facilitators to the implementation of patient navigator programs worldwide. Existing recent reviews (i.e.: those published within the past 5 years) in the area of patient navigation have tended to focus on cancer (28), fail to consider grey literature (16) where implemented programs may be described or have not narrowed their search to the adults with complex needs population (but rather all adults aged 18 or older (29), who may be better suited by youth programs (30) or pediatric populations (31)). Existing reviews also do not report on the role of family caregivers within existing programs. Methods and analysis: Study Design A scoping review methodology, which is a type of knowledge synthesis used to identify areas of consensus and gaps in knowledge, was chosen as the study design (32). Unlike systematic reviews, scoping reviews do not aim to assess the rigour of given research findings and allow for a more expansive, exploratory approach (32). The protocol for this scoping review is drafted based on Arksey and O’Malley’s five-stage methodological framework statement (33) and the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (34). Arksey and O'Malley’s method includes the following steps (1) identifying the research question, (2) identifying relevant studies, (3) screening and selecting studies, (4) charting the data, (5) collating, summarising and synthesising the results and finally, (6) consulting with stakeholders (33). Step 1: Identifying the Research Question The research team collaborated with stakeholders (i.e., a current patient navigator, representatives from a not-for-profit community support service agency, the Director of Interprofessional Practice from a large urban hospital), to define the research question for this review. Questions were also informed by the CFIR (26).We identified the following five research questions: 1.What is the scope of patient navigation programs available for adults age 26 years or older with complex needs?; 2) Who are the target patients of the existing programs? 3) When and how were these programs are developed and implemented? 4) What are the content of the programs and how does the content of these programs change to meet the needs of patients and families; 5) What are the reported impact of these programs on patient and caregiver outcomes? We define patient navigation programs as a model of care whereby a partnership is formed between a patient and/or family and the patient navigator, who aims to provide navigational support to accessing health and/or community resources and provides informational and emotional support (12, 35, 36) . Step 2: Id

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