Patient Navigator Program Tools

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Summary prepared by the AETC Engagement in Care Workgroup


  • Demographically-related peers or lay health workers function in a complementary capacity with clinic staff to assist patients access, and engage in, medical and supportive services while working to address patients' knowledge, communication and literacy gaps, and enhance health-promoting behaviors.


  • Principles of patient navigation are rooted in community (lay) health worker and peer-based intervention strategies;
  • methodology of patient navigation is well described in the non-HIV literature and has been incorporated into a number of disease prevention and management models, including those for cancer, diabetes, asthma, CVD, and maternal and child health. In the context of HIV, longitudinal data from a HRSA SPNS demonstration grant (Bradford, 2007) found improved engagement in care and viral load suppression associated with patient navigation.
  • Patient navigation can be implemented by a clinic or in collaboration with community-based service organizations; can also be tailored to site-specific needs and resources.


  • Limited prospective evaluations and/or cost-benefit analyses of patient navigation for any disease, particularly related to morbidity and mortality outcomes.
  • Reimbursement sources may be limited.
  • Patient navigator responsibilities that overlap with other clinic staff may create confusion and billing difficulties.
  • Lack of standardized training programs for navigators.

Resources Required

  • Senior clinic leadership support.
  • Full integration of patient navigation in to outcomes planning and strategies.
  • Development of navigator training programs and mechanisms for ongoing evaluation of fidelity and outcomes.
  • Coordination of staff and/or collaboration with community-based service organization to provide adequate training for patient navigators.
  • Training of existing clinic staff.

Model Programs



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