Community Linkage Through Navigation to Reduce Hospital Utilization Among Super Utilizer Patients: A Case Study.

This paper describes a program model that uses hospital- and community-based patient navigators and social workers to link super utilizers of the hospital system with existing community resources to improve access to services and appropriate care while lowering hospital utilization. A case study is used to illustrate a typical super utilizer patient who is homeless and has psychosocial issues. The navigator's and social worker's roles and approaches are described, and specific community linkages for this case are listed. The navigator discusses her experience and lessons learned working with this patient. Program and patient outcomes are shared.