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Patient Experience Manual

The Health Systems Science curriculum Patient Experience Manual is designed to be a guide for students in the patient experience program at Penn State College of Medicine. Learn more about the patient experience here.

The purpose of the manual is to answer questions that students might have prior to and during the patient experience program. The creation of this manual resulted from feedback sessions with students in the patient experience program and their site mentors and is updated frequently.

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What is Patient Navigation?

Patient Navigation Origins in Oncology Expand answer

Harold P. Freeman pioneered patient navigation in 1990, when he developed the intervention in Harlem to decrease disparities in access to the diagnosis and treatment of cancer. The program worked with underserved and underinsured breast cancer patients. The intervention was highly successful and has been implemented in health systems across the nation.

Student Patient Navigator Definition Expand answer

A student patient navigator is a trained medical student who guides patient(s) through a complex health care continuum. Student navigators provide information, educate patients (e.g., medical care plan, available community resources, etc.), offer emotional support and facilitate coordination and continuity of care (e.g., identifying barriers, etc.)

Student Patient Navigation at Penn State College of Medicine Expand answer

To be effective student patient navigators and future physicians, knowledge, attitudes and skills are required to improve a patient’s health. There are three key functions:

  • Students must be able to provide information and educate patients about aspects of their disease, medical care plans and various factors related to medical care, including psychological, social and systems-related factors.
  • Students must be able to provide emotional and supportive care to patients about all aspects of their medical illness, including the biological, psychological and social factors that, in sum, present a complexity that can be overwhelming to patients.
  • Students must be able to facilitate coordination and continuity of care for patients requiring navigation within the health care system. This includes identifying patient-specific barriers to obtaining high-quality health care and mediating solutions for these issues.

Potential Student Patient Navigator Roles

Monitor Patient Progress with Care Plans Expand answer
  • Facilitate an implementation plan to resolve patient issues.
  • Perform follow-up patient contact after new diagnoses to assess understanding and review plans.
  • Ensure patients are receiving the appropriate testing.

Patient navigation example: Students at Pinnacle Medical Group place phone calls and make home visits to help resolve any issues a patient may experience with their care plan.

Aid in Patient Education Expand answer
  • Explain the clinical process (e.g., appointments, treatment plan, etc.).
  • Answer patient and family questions about care and diagnosis.
  • Aid in health literacy (e.g., help patients understand the results).

Patient navigation example: Students at Penn State Surgical Weight Loss partner with the dietitian to help facilitate a healthy nutritional plan for the patient.

Provide Emotional and Psychological Support Expand answer

Patient navigation example: Students at Penn State Health Medical Group – Fishburn Road call patients to discuss any personal or family issues.

Perform Patient Assessments Expand answer
  • Perform intake interviews with patients and acquire a medical history.
  • Complete home visits to explore the patient’s context and identify barriers in care.
  • Investigate underlying causes to patient’s non-compliance to care plans.

Patient navigation example: Students at UPMC Pinnacle complete home visits to investigate the causes of non-compliance. They help patients apply for insurance, receive transportation and obtain the necessary resources for their health.

Provide Health Promotion and Coaching Expand answer
  • Help patients in medical decision-making.
  • Encourage the patients to follow their care plan.
  • Provide wellness promotion.

Patient navigation example: Students at the Department of Health tuberculosis clinic encourage patients to follow their care plan and also educate patients on habits that may harm their health, such as by providing smoking cessation information.

Facilitate Patient Access to Services and Resources Expand answer
  • Educate patients on community resources.
  • Help with medical assistance or disability services.
  • Aid in identifying high-risk health insurers.

Patient navigation example: Students at Lebanon Volunteers in Medicine help patients obtain shower chairs and apply for Medical Assistance.

Assist with Medication Reviews Expand answer
  • Assess medication understanding.
  • Gauge patient compliance with medications.

Patient navigation example: Students at Lancaster General Care Connections partner with care navigators to attend home visits and review patient’s medications.

Arrange Transportation Expand answer
Facilitate Communication and Coordination Expand answer
  • Coordinate follow-up appointments (e.g., specialists, primary care providers).
  • Help overcome patient barriers prior to discharge.
  • Be a liaison between patient and provider.

Patient navigation example: Students at Holy Spirit Hospital coordinate follow-up primary care provide appointments for patients.

Improve the Clinical Process Expand answer
  • Assist in identifying high-risk patients.
  • Create new community connections and partnerships to improve patient care.
  • Serve as trainers and mentors to new medical students.

Patient navigation example: All experienced student patient navigators will help train the new class of patient navigators.

Potential Patient Barriers Encountered in Navigation

This section illustrates four different categories of barriers that students may come across during the patient navigation experience: systems barriers, clinic barriers, patient barriers and provider barriers.

Systems Barriers Expand answer

There are several different types of systems barriers that may be encountered by patients, spanning the larger health care system to issues related to medications and communication.

Insufficiencies in system

  • Patients discharged without follow-up appointment arranged prior to discharge.
  • Long wait times for a referral appointment to a specialist or primary care physician.
  • Lack of or insufficient community resources.
  • Electronic health record (health information) not accessible between sites.
  • Health insurance challenges that make eligibility process difficult.
  • Multiple provider and specialist appointments occur at different locations and times.

Provider or service access

  • Lack of or absence of sufficient service access (e.g., mental health services, educational services).
  • Lack of or absence of primary care clinic access in area/region.
  • Lack of or absence of consultant services in area/region.
  • Insufficient services due to the increasing age of the U.S. population.
  • Lack of sufficient provider time.

Insurance access

  • Medical Assistance.
  • Underinsured or no insurance (e.g., not eligible for state or federal insurance plans).

Medication issues

  • Medication reconciliation challenges between providers.
  • Numerous medications prescribed for multiple conditions (e.g., polypharmacy).
  • Issues in authorization of medications.
  • Cost of or funding for medications.

Communication breakdowns

  • Poor communication between providers (e.g., within and between clinics).
  • Poor communication between providers and patients.

One Navigator’s Experience

Elise Madar, Class of 2018

“One of my patients suffered from severe renal osteodystrophy, which left her bedridden and on dialysis. This patient faced many barriers, but one that sticks out clearly in my mind was transportation to her dialysis appointments. This patient had an ambulance company, paid for by insurance, pick her up from her house and take her to and from dialysis three times a week. Insurance had also paid for a fitted mobile chair for this patient. However, as the disease progressed, her bones kept deteriorating, and this patient could no longer fit safely in the chair. During the time I was helping this patient with other issues, the insurance company decided it would no longer pay for the ambulance company because they had already supplied this patient with a chair. This left the patient with no transportation to her dialysis appointments and no usable mobile chair. Unfortunately, we were not able to overcome this barrier by the end of the year due to all of the complexities of this issue. In a situation like this, there is not much you can do as a navigator except gain awareness of these compound barriers that are encountered so frequently in our health care system and try your best to learn how to overcome them in the future.”

Clinic Barriers Expand answer
  • Long wait times for and difficulties in arranging follow-up appointments in clinic.
  • Insufficient staff numbers (e.g., appointment times are too short, providers unavailable).
  • Clinic hours are irregular and do not meet patient needs.
  • Inconsistencies in workflow (e.g., inconsistent documentation, breakdowns in patient charting).
  • Technology not up-to-date (e.g., paper charting).
  • Limited resources within clinic (e.g., teaching tools).
  • Limited capacity for patients in terms of space within clinic.
  • Patients are put into the position where they are fulfilling staff roles (e.g., requesting documents).
  • Clinic rooms are not functional as exam rooms (e.g., no sink in room).
  • Geographic locations of various clinics within the same provider network.

One Navigator’s Experience

Connor Carmichael, Class of 2018

“As a patient navigator, I worked at a free clinic that acted as a primary care clinic for uninsured people in the area. This model worked very well because it allowed continuity of care and real family medicine, rather than an urgent-care model, which is employed at some free clinics that I have seen. However, there were several barriers I saw at my clinic, such as the incomplete transition to electronic medical records. However, the most difficult barrier faced was getting specialty care for patients. Since the patients don’t have the money for primary medical care, and specialty care costs can be even higher, particularly procedures, the clinic has to find specialists who are willing to consult pro bono. However, they have not been able to find any clinics in urology or orthopedics that are willing to take on the patients. This was particularly troubling when a patient came in with osteomyelitis of the foot resulting from a diabetic ulcer. The staff and navigators had to actually apply for Medical Assistance with her so that she could be admitted to the hospital for IV antibiotic therapy. The clinic is still searching for specialists who will accept patients without charge so they can continue offering continuous care to their patient base.”

Patient-Related Barriers Expand answer
  • Perceived non-compliance with recommendations and plans.
  • Lack of adequate housing.
  • Poor finances (e.g., inability to pay electric bills, out of work, unable to make mortgage payments, unable to afford healthy foods).
  • No transportation to attend clinic appointment.
  • Lack of health literacy (e.g., understanding clinical processes); patient speaks different language than clinic providers.
  • Co-morbidities make it difficult to follow care plans.
  • Stigma of mental health, denial, addiction.
  • Overwhelmed with care plan.

One Navigator’s Experience

Max Hennessy, Class of 2018

“Sometimes the hardest barriers you face during patient navigation are the patients themselves. Many patients who require navigation have personal issues that make successfully treating them more difficult, such as a low education level and poor health literacy, mental health issues such as anxiety and depression, and other general problems such as non-compliance. For example, during my time as a navigator, I worked with a patient who almost seemed to enjoy being sick. Whenever I would speak with her there was always a symptom or disease she thought she was suffering from. During one of our encounters the patient asked me to schedule an appointment with an orthopedic surgeon because she was convinced she had osteogenesis imperfecta or “brittle bone disease.” Despite me thoroughly explaining the disease to her and describing why she did not have it, she still demanded an appointment. In a situation like this, it becomes easy to argue with a patient, but this will accomplish nothing other than to upset the patient and damage your relationship with them. The best thing to do is to tell the patient that you will consult with your superiors, and will schedule the appointment for them if they agree that the appointment is necessary.”

Provider-Related Barriers Expand answer
  • Providers have limited time to address patients’ needs.
  • Providers are unaware of patients’ social issues at home, unaware of resources available to help their patients.
  • Lack of understanding of different cultural backgrounds.
  • Patient-directed decision-making rather than patient-centered care.
  • Patients feel that they cannot trust their physician.
  • Provider is unaware of prescription costs.

One Navigator’s Experience

Laura Leuenberger, Class of 2018

“As a navigator, I helped patients to schedule a post-discharge appointment with a primary care provider. This involved figuring out if a patient was, in fact, going to be discharged. In one case, a confused older woman was on the ‘maybe’ list to being discharged in the next few days. Because the patient was a poor historian, and the chart incomplete, I asked the floor nurses for advice. They didn’t know, but gave me the physician’s number to call. He told me he was too busy to figure that out now, but she’d be discharged ‘soon.’ I next attempted to make her follow up appointment, calling her listed PCP. Unfortunately, the listed PCP had recently retired, and the office said that the family had been told who the new provider would be. Trying to be thorough, I called her listed contact (her daughter) to find this new PCP. Reasonably, the daughter was more concerned to find out if her mother was being discharged that afternoon. Since the patient lived with her daughter (who worked full-time), she needed to coordinate the necessary essentials. I felt like I was just adding a layer of confusion, all because the physician had not talked to the patient or the family in a few days, and no one knew what was going on. Feeling like there was nothing else for me to do, I ultimately left a note in the chart that the daughter wanted to be contacted, and spoke to the nurses and the resident, hoping this would happen. A breakdown in communication is obviously not one individual’s fault, but I felt that the providers were not concerned about remaining patient-centered, nor were they able to spend the time to try to do so. As a navigator, you can only try your best, and try to point out these flaws in the system to the individuals who work with them daily. Providers can only operate within the constraints of the system, but that doesn’t make it less frustrating for the patients!”

Professional Boundaries

Student Patient Navigators work closely with patients, and develop a close bond through providing emotional support. At times, the line between the professional and personal relationship may become blurred. This page contains a list of boundaries that navigators should follow; note this is not an exhaustive list, and navigators may come across more boundaries during navigation.

Student Professional Boundaries Expand answer
  • Students should travel in pairs when making home visits.
  • Students should notify the site mentor prior to making a home visit.
  • When making home visits, students should ensure they are traveling to a safe area.
  • Students should not enter the home of a violent/distraught patient.
  • Students should only transfer protected patient information via an encrypted email or USB.
  • Students should not share their cell phone number or provide any personal information to patients.
  • Sites were asked to not to give students’ personal phone number to patients.
  • Students using a personal cell phone to call patients should dial *67 first; the phone number will read as “unknown” to the person receiving the call.
  • Students should not carry any patient’s medications in their personal belongings.
  • Students should not give medical advice or provide counseling services.
  • Students should not provide any medical advice that has not already been shared with a patient.
  • Students should not provide transportation to patients.
  • Students should not accept any gifts from patients.
  • Students should not share any patient information on social media (Twitter, Facebook, Instagram, etc.).
  • Students should not provide any personal information that is not helpful to the patient.
  • Students should dispose of all patient protected health information in designated hospital trash cans.
  • When leaving messages for patients, students should not disclose any medical information.
  • Students who are asked a question that they are not qualified to answer, or to which they do not know the answer, should refer the patient to the site mentor.
Professional Boundaries Examples Expand answer

Example 1

“Knowing When to Intervene” by Katherine Sittig, Class of 2018

“Part of what makes patient navigation a challenging experience is the newness of the role – at best, the patients and the site supervisors were introduced to the term ‘patient navigator’ a little over a year ago, and much of the past year has been spent defining the role in terms of a specific context. This past spring, I was put into a situation that forced me to decide what action to take as a navigator, despite the fact that my role had been left relatively undefined.”

“In March, my navigation partner and I found out that we would get to accompany my patient during a medical appointment. This would be a new experience for us, as we had previously only done home visits. Since the exam room was fairly small, we decided that it would be best if only I and the nurse supervisor went into the room with the physician and my patient. My patient had come to the office with a sore throat, but did not have a PCP established, and so was seeing a new physician for the first time. The visit started off well, with my patient even asking the doctor if she could become her PCP. Things quickly went south, however, once the conversation turned to treatment. Another physician had prescribed my patient Tylenol with codeine for her pain ‘to tide her over’ until she was able to come in for another appointment. My patient had a history of drug use, and so the new physician was unwilling to prescribe her codeine, and proposed a combination of three different medications as an alternative. My patient became upset, saying that she had tried one of those drugs before, and needed the new physician to prescribe her more Tylenol with codeine because she knew what her body needed. The nurse supervisor tried to step in, but tensions rose, and I was left wondering whether I should intervene. I ended up staying quiet as the patient finally stood up, grabbed her things, and stormed out of the exam room.”

“Afterward, I felt conflicted about whether I, as a patient navigator, should have spoken up. On one hand, it was my duty to help my patient interact with the health care system in the best way possible, and clearly, this was a negative experience for everyone involved. On the other hand, I was in an exam room, the domain of the physician, and the nurse supervisor knew the patient much better than I did. If I had said something, would the patient have listened to me? If I had spoken up, would that have negatively affected the way the patient saw the role of the patient navigator? I eventually made peace with my decision, deciding that my input would only have added to the tension in the room, and that would have hurt my ability to navigate this patient in the future. For me, this experience helped me define what it means to be a patient navigator, and serves as an example of how one must decide what is within the scope of the patient navigator role.”

Example 2

“Knowing your Limitations” by Laura Brubaker, Class of 2018

“I was once asked to ‘help’ a site employee with medication reconciliation and disposal for a home-bound patient. I agreed because I was assigned to shadow the employee, and this was part of the employee’s navigator role. In this situation, I was not alone and the employee essentially completed the tasks. However, later, as I thought about it, I realized I would not agree to complete any independent part of this particular activity in the future. If a medication would go missing, the student could be accused of wrongdoing. It’s OK to decline a task (or ask the office and Penn State to help you make the task a less risky one) as long as you use good communication and explain why you are concerned. It may feel that you are being an inconvenience, but you need to do what will be safe for everyone, including yourself.”

Student Guides and Resources

Acronyms Expand answer
  • ACT: Assertive Community Treatment
  • ADA: Americans with Disabilities Act , 1991
  • ADL: Activities of Daily Living
  • ALOS: Average Length of Stay
  • BHDS: Behavioral Health Developmental Services
  • CAH: Care at Home
  • CAT: Capital Area Transit
  • CBT: Cognitive Behavioral Therapy
  • CM: Case Manager or Case Management
  • CMU: Case Management Unit
  • CMS: Centers for Medicare and Medicaid Services
  • COINS: Coinsurance
  • COPS: Comprehensive Outpatient Program Services
  • CPS: Child Protective Services
  • Delta (Δ): is a commonly used symbol for change
  • DHS: Department of Human Services
  • DME: Durable Medical Equipment
  • DOH: Department of Health
  • EAP: Employee Assistance Program
  • FA: Family Assistance
  • FCH: Family Care Home
  • FFS: Fee for Service
  • HDM: Home Delivered Meals
  • HH: Home Health
  • ISP: Individual Support Plan
  • LHA: Local Housing Authority
  • LOC: Level of Care
  • LT: Lebanon Transit
  • LTC: Long Term Care
  • MA: Medical Assistance
  • MAW: Medicaid Waiver
  • NF: Nursing Facility
  • OOA: Office of Aging
  • OOP: Out of Pocket
  • PHP: Permanent Housing Program
  • POA: Power of Attorney
  • PPI: Pennsylvania Psychiatric Institute
  • PSA: Protective Services for Adults
  • SELHS: South East Lancaster Health Services
  • SES: Socio-economic Status
  • SNF: Skilled Nursing Facility
  • SOS: Senior Outreach Services
  • SSA: Social Security Administration
  • UM: Utilization Management
Better Care Playbook Expand answer

The Better Care Playbook offers information about improving care for people with complex health and social needs.

The playbook was desiged to improve the health outcomes and daily lives of individuals in the United States with the most complex care needs and was created by six foundations — The Commonwealth Fund, The John A. Hartford Foundation, Milbank Memorial Fund, Peterson Center on Healthcare, the Robert Wood Johnson Foundation and The SCAN Foundation – in partnership with the Institute for Healthcare Improvement.

Home Visit Checklist Expand answer

Home Visit Prep

  • Where are you going? Is it a safe area?
  • Confirm directions and share contact information with site mentor.

Patient Priorities

  • Ask open-ended questions to learn the patient’s perception of their medical problems and what they doing to fix their problems.
  • No more than three goals at a time, and less if the patient seems overwhelmed.

Action: Use active listening techniques to confirm you have a clear understanding of what the patient feels is important

Appointment Preparation

  • Ensure that the patient is aware of their appointments.
  • Is the patient prepared to attend their appointments?
  • Does the patient have transportation to and from the appointments?

Action: Help them develop a list of questions to take with them. If needed, help the patient locate transportation.

Medication Review

  • Review medications.
  • Check medication adherence or reasons for not purchasing or taking medication.
  • Discuss cost concerns, patient deductibles, etc.
  • What system does the patient use to dispense their medications: pill box, from the bottle directly, or other means?
  • Does the patient have any discontinued medications?
  • Check the pill count against the label/instructions (this will verify if the patient is taking it correctly).

Action: Direct any questions about medications to the nurse or physician who are handling these issues.


  • Ask the patient about their experience with using insurance.
  • Does the patient need to get pre-authorizations?
  • Discuss cost concerns, patient deductibles, etc.
  • Does the patient’s insurance cover their appointments?

Action: Direct patients to the staff who are handling these issues. If you are not sure, assist with a call to insurance member services. You may need the insurance ID and NPI number.

Insurance Overview Expand answer
Members of the Medical Team Expand answer
  • Physicians: Diagnose and develop treatment plans for patients; teach medical students and residents; work collaboratively with the health care team; provide reports and updates on the patient’s condition; provide referrals to other specialists or services; educate patients on their disease(s); serve as an advocate for patients and families; help patient navigate through a complex medical system; provide patient-centered care in a cost-effective way.
  • PAs: Practice medicine with the supervision of a licensed physician. Provide a wide range of medical services.
  • Advanced Practice Clinicans: Examples include nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse-midwife (CNM) or certified registered nurse anesthetist (CRNA). These providers have full prescriptive authority and may practice without any required collaborative agreement with a physician (laws vary by state).
  • RNs: Roles vary greatly depending on setting; can assist physician in office by taking vitals, administering vaccinations and performing certain tests, or work in the hospital setting monitoring patient status, administering medications, etc.; can provide care to patients in their home; many other roles for RNs exist.
  • Pharmacists: Dispense drugs and medications prescribed by physicians, physician assistants, nurse practitioners, veterinarians and dentists; advise health care professionals and patients on the use and proper dosage of medications, as well as expected side effects and interactions with other prescription and non-prescription medicines; recommend other forms of medication (liquid, tablets, capsules, compound, flavorings, etc.) to improve compliance; recommend strategies to improve medication compliance.
  • Nutritionist/dietician: Advise patients on nutrition (foods to avoid, foods to consume, etc.); can design specialized diets (weight loss, low-sodium, low-cholesterol, low-fat, restricted-fluid, ketogenic, etc.); work with physicians to recommend diets for patients; teach patients about nutrition topics.
  • Mental health provider: May be licensed clinical social workers (LCSW) or a master of social work (MSW), psychologist (PsyD, or PhD), licensed professional counselor, psychiatrist (MD) or other. They provide mental health services such as diagnosing mental illness, providing talk therapy, medication management and other modalities.
  • Interpreters: Assist health care professionals in communicating with the patients in their native language. These individuals make the patient comfortable in the medical setting as well as allow the patient to communicate with the health care team. Many hospitals have translator phone lines, which allows many languages and dialects to be accommodated.
  • Social workers: Provide counseling and enable individuals, families and communities to obtain social services. They work with clients on issues of unemployment, illness, disability, housing, abuse and financial problems. Social workers specializing in providing mental health services and counseling are called clinical social workers. In the community, they may be active in organizing communities to improve health and social services. Social workers often assist families in crisis situations and during periods of transitions.
  • Physical therapists: Examine patients and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function and prevent disability through the use of various exercises, modalities such as therapeutic ultrasound, heat, ice, massage and others. Can help recover from neurological, orthopedic, chronic pain, urinary incontinence and vestibular illness or injury.
  • Occupational therapists: Treat ill, injured or disabled patients through the use of everyday activities in order to help them achieve maximal independence in performing activities of daily living. Can provide assistive devices to help patients work independently (grabbers, dressing aids, hygiene aids, etc.)
  • Speech therapists: Speech language pathologists help to prevent, diagnose and treat disorders of speech, swallowing, social communication and cognitive communication disorders. Can provide treatment for dysphagia, oral motor disorders, cognitive impairments, fluency, stuttering, voice disorders and other.
  • Chaplains: Provide spiritual support for patients and caregivers; consult with patients, family and staff on ethical issues; work with medical professional to sensitive them toward cultural and spiritual aspects of a patient’s care.

This online tutorial from the Patient Navigator Training Collaborative walks students through the various members of the medical team.

Orienting New Patient Navigators Expand answer

Introduce the new navigators to the clinical site

  • Provide a tour of the facility/clinic/office.
  • Introduce the navigators to staff members.
  • Provide literary articles related to the site.
  • Create a binder or folder with materials that may be used at the site.

Connect them to experienced navigators

  • Learn the navigation process through their peers.
  • Understand their role.
  • Hear applicable cases that are relevant to their role.

Train Students in site’s Electronic Medical Record

  • Students should be able to use the EMR as appropriate.

Shadowing for the first two visits

  • Have students shadow navigator or social worker role to gain a better understanding of their role.

Experiential learning

  • Have students work in pairs to practice their role.
  • Students can help patients complete insurance forms, access forms, etc.
  • Students can ask the patient questionnaires.
Senior Living Facility Overview Expand answer
Stages of Change Expand answer

The five stages of change were developed by Carlo C. DiClemente and J.O. Prochaska. The process describes the series of changes people go through to alter lifestyle habits.

The five stages are pre-contemplation, contemplation, preparation, action and maintenance.

To help gauge the important of change to the patient, navigators can ask the following “change ruler” questions:

  • On a scale of 0 to 10, how important is it for you right now to change? (O is not important at all; 10 is extremely important.)
  • On a scale of 0 to 10, how confident are you that you could make this change? (O is not confident at all; 10 is extremely confident.)
Student Patient Navigator Cycle Expand answer

The patient navigator experience follows a cycle:

Getting/Building the Story

This stage involves listening and seeking out the back-story of a patient.

  • Life story: “Can you tell me a little about yourself? I’m interested in your story – growing up, family, work, hobbies, things like that. What is most important to you?”
  • Illness experience: “What has this illness been like for you? What has been hardest? What has helped you? What are you hoping for?”
  • Explanatory model: “I’m interested in hearing what you are thinking about your medical problem. What do you think is going on? What do you worry about the most?”

Making a Diagnosis

This stage involves identifying the challenges and barriers faced by the patient and asking “why?” Challenge contexts may include individual/family, social network, community and societal issues. Potential barriers may be disabilities, housing, support, transportation, finances or insurance.

Telling the Story

This stage involves communicating with the interprofessional team and performing navigator hand-offs.

Making a Difference

This stage involves creating and implementing a plan, and empowering the patient with shared decision-making and accountability.


This stage involves the navigator identifying boundaries. What is the navigator role? What are the limitations? This is also the time to critique personal assumptions/biases and recognize learning needs.

Working with CareConnect/EMR Expand answer

Assistance is available using CareConnect, the electronic medical record system of Penn State Health.

See CareConnect training on the Infonet
(internal access only; login required)

Patient Question Guides

Inpatient Discharge Question Guide Expand answer

Work with the patient through these questions:

  • Are you ready to leave the hospital?
  • Do you understand your discharge instructions?
  • Did you report all of your symptoms to your physician prior to discharge?
  • Do you understand how to keep your health problems from getting worse?
  • Do you have transportation home, to your appointments and to pick up prescriptions?
  • Are you able to fill your prescriptions?
  • Do you understand the potential side effects of your prescriptions?
  • Do you understand what follow-up appointments you need to make after discharge?
  • Do you understand how to access your medical records?
  • Do you know who to contact for questions/concerns/updates?
  • Have you been involved in the medical decision-making?
  • Can you direct your family/caregivers in how to assist you in your care?
  • Do you understand what kind of equipment and supplies are being prescribed to you (i.e., walker, wheelchair, shower chair, etc.) and how to use them?
  • Do you understand what supplies your insurance will cover?
Inpatient Rehab Discharge Question Guide Expand answer

Work with the patient through these questions:

  • Do you understand what kind of equipment and supplies are being prescribed to you (i.e., walker, wheelchair, shower chair, etc.) and how to use them?
  • Do you understand what to expect during recovery? Do you understand what has happened to you?
  • Do you understand who you should call if you have a problem obtaining supplies and have contact numbers/names?
  • Do you understand what supplies your insurance will cover?
  • Do you have transportation to your follow-up appointments or understand how to access public transportation?
  • Do you know what day and time you are being discharged? Do you have transportation?
  • Have you been involved in the medical decision-making?
  • Do you understand what medications you are taking, when to take them and how they differ from your previous medications?
  • Are you able to direct family/caregivers on how to assist you in your care?
  • Do you know what provider to contact with questions/concerns/updates?
  • Do you understand what follow-up visits and why they have been scheduled? Do you understand why you need to have a follow up visit with your PCP?
  • Do you know the location and time of your outpatient therapy?
Mental Health Discharge Question Guide Expand answer

Work with the patient through these questions:

  • Is there anything new in your situation since discharge?
  • Is there anything else on your mind, questions or concerns?
  • Do you have access to your discharge instructions? When are you going to your follow-up appointments?
  • How do you keep track of your appointments? How are you getting to your appointments?
  • Have you filled your prescriptions since you left the hospital?
  • Do you have enough medication until your next appointment with the doctor?
  • Would you like to talk to someone about your medication?
  • Do you have concerns about side effects?
  • Is there anything else that you need from me?
Primary Care Clinic Question Guide Expand answer

Work with the patient through these questions:

  • Do you have any questions or concerns regarding your care?
  • Have you seen your provider?
  • What concerns do you have with maintaining your health?
  • Do you know what follow-up appointments you need to make?
  • Do you have any copays?
  • Do you have transportation to your appointments and/or to pick up prescriptions?
  • Are you able to fill your prescriptions?
  • Do you understand the side effects to your prescriptions?
  • How many times in the past week have you missed taking your medication?
  • Do you understand how to access your medical records?
  • Do you know who to contact for questions/concerns/updates?
  • What are the biggest goals or changes you wish to make in your life in the next three months?
  • Is there anything else you need from me?
Underserved/Underinsured Clinic Question Guide Expand answer

Work with the patient through these questions:

  • Do you have any questions or concerns regarding your care?
  • How long have you lived in your current location? Are you having any issues with rent or utilities?
  • What is your insurance carrier? What is your copay?
  • Do you have transportation to your appointments and to pick up your prescriptions?
  • Are you able to fill your prescriptions?
  • Do you know who to contact for questions/concerns/updates?
  • Who do you call when you’re having a terrible day?
  • Are you interested in speaking to a professional about your life?
  • Do you feel safe currently? Have you ever been threatened?
  • What are the biggest goals or changes you wish to make in your life in the next three months?
  • Is there anything else you need from me?