Patient Navigation

A key part of the longitudinal Systems Navigation Curriculum at Penn State College of Medicine is the patient navigation program.

As patient navigators, students begin learning about health care delivery in their first year of study by serving as guides, helping patients navigate through the sometimes-complicated process of getting the care they need.

Through patient navigation and the three health systems courses, students begin to develop the knowledge, skills and attitudes to function effectively amid the complexities of an evolving health system.

This page lists resources for patient navigators, both to help them in the navigation experience and that they might provide to patients they are assisting.

Each navigator is evaluated both mid-year and at the end of the navigation year. To see a sample of the evaluation form, email Deanna Dubots at ddubots@pennstatehealth.psu.edu.

In addition to the resources on this page, a full manual is available for patient navigators.

See the Patient Navigation Manual

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Site-Specific Information: Penn State Health Locations

Breast Center Expand answer

Penn State Health Breast Center, 30 Hope Dr., Suite 1800, Entrance A, Hershey, PA 17033

Site mentor: Dr. Melody Paulishak

Site description: Site experiences may include the following.

  • Attending multiple patient appointments.
  • Assisting patients with community resources and appointment prep.
  • Assisting with completing and providing a treatment summary/care plan to the patients at the visit.
  • Making follow-up phone calls after appointments.
  • Conducting home visits after surgery.
Eating Disorders Clinic Expand answer

Eating Disorders Clinic, 905 W. Governor Road, No. 200, Hershey, PA, 17033

Site mentors: Dr. Martha Levine, MD (Associate Professor of Pediatrics, Psychiatry and Humanities and Director of the Intensive Outpatient and Partial Hospitalization Programs, Division of Adolescent Medicine and Eating Disorders); Amy Ethridge, MS, OTR/L (occupational therapist and clinical psychiatric specialist, Adolescent Medicine and Eating Disorders)

Site description: Site experiences may include the following.

  • Providing follow-up/accountability for patients’ relapse prevention plans.
  • Home visits or grocery shopping trips as needed.
  • Helping patients to identify and overcome any barriers to recovery.
I.O. Silver Cardiovascular Specialties Clinic Expand answer

I.O. Silver Cardiovascular Specialties Clinic, 200 Campus Dr., Suite 600, Hershey, PA 17033

Site mentor: Patricia Williams-Forgenie (senior attending nurse)

Site description: Site experiences may include the following.

  • Meeting with heart failure patients.
  • Home visits with patients.
  • Following patients longitudinally through the care continuum.
Life Lion EMS Community Paramedicine Expand answer

Life Lion EMS Community Paramedicine

Site mentor: Brandon Wattai (program supervisor of Life Lion Community Paramedicine)

Site description: Life Lion EMS Community Paramedicine is a dedicated group of paramedics who perform home visits for patients, typically in a post-discharge timeframe. A division of Life Lion EMS, within the Department of Emergency Medicine, Community Paramedicine is tasked with post-acute care of heart failure, VAD and stroke patients. Additionally, on request, visits can be performed for high-risk or high-utilization patients identified by EMS crews. During these encounters, paramedics reinforce discharge instructions, evaluate safety, reconcile medications, assess physical status and disease progression, identify unaddressed medical and social needs, and work to provide critical system navigation.

Patient Navigation with Dr. Paul Haidet Expand answer

Patient Navigation with Dr. Paul Haidet, Penn State Internal Medicine, 10 Conference Dr., Hershey, PA 17033

Site mentor: Dr. Paul Haidet (physician)

Site description: Experiences may include the following.

  • Navigating up to four patients.
  • Monthly meetings with Dr. Haidet.
  • Home visits.
  • Attending patient appointments.
  • Working independently to locate resources for patients.
Patient Navigation at Fishburn Road Family Practice Expand answer

Patient Navigation at Fishburn Road Family Practice

Site mentor: Karen Newman (clinical case manager for Penn State Medical Group Fishburn Road family practice)

Site description: Responsibilities may include the following.

  • Navigating patients with chronic illness.
  • Working closely with nurse coordinator and social worker.
  • Finding patient records.
  • Communicating with care manager.
  • Doing appointment reminders.
  • Contacting agencies on behalf of the patient.
  • Regularly calling patients to receive updates.
  • Identifying barriers through active listening. Common barriers encountered include access to care, access to mental health treatment, access to transportation and cost of medications.
Patient Navigation with Pam Carr Expand answer

Patient Navigation with Pam Carr, 1249 Cocoa Ave., Hershey, PA 17033

Site mentor: Pam Carr (social worker)

Site description: Site experiences may include the following.

  • Working with four patients long-term over the year.
  • Getting to know patients on a personal level.
  • Working with patients with complex chronic diseases.
  • Coordinating public transport, organizing appointments, assisting with medication organization and scheduling.
Penn State Cancer Institute Expand answer

Penn State Cancer Institute, 400 University Dr., Hershey, PA 17033

Site mentor: Dr. Michael Hayes and team

Post-Acute Care Expand answer

Post-Acute Care Hub at Penn State Health Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA 17033

Site mentors: Dr. Nicole Osevala (physician); Kelly Thrush, Loretta Tootchen and/or Tara Keener (nurse practitioners)

Site description: During the patient navigation experience with the post-acute care program, students have the opportunity to follow assigned patient(s) from hospital discharge through their admission to the skilled nursing rehabilitation facility and then home, including clinic visits.

Students will work with a Penn State Health nurse practitioner designated at each site. Utilizing Powerchart in CareConnect as well as the medical record utilized at the skilled nursing rehabilitative site, students will become familiar with the patient(s) and use Powerchart to communicate with the health care team.

Navigators meet with patients/families at the time of admission to the skilled nursing rehabilitation site; visit their patients while they are receiving rehabilitative care and again near discharge from the skilled nursing site; identify barriers that may impact them at home, including social, physical and medical issues; and develop a plan.

Following a patient’s discharge home, the student utilizes both phone calls and, when possible, a home visit with the RN care manager or student partner to reassess the patient and continue the navigation experience. A Penn State Health RN care manager will, in the majority of cases, follow the patient through 30 days post-hospital discharge.

Students are encouraged to interact with the RN care manager to maximize the navigation experience and impact.

An assessment form will be provided to the navigator and a written plan prior to discharge home and again after discharge home will be submitted to the site director. Discussion of assessments and new navigation issues will be held one-on-one and/or in site-group cohorts at the end of each visit.

Pre-Anesthesia Clinic Expand answer

Pre-Anesthesia Clinic at Penn State Health Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA 17033

Site mentor: Charlynn Duncan (nurse practitioner)

Site description: Site experiences may include the following.

  • Shadowing nurse practitioners.
  • Observing patient surgeries.
  • Providing patient with access to transportation.
  • PCP contacts.
  • Many conversations with patients to identify barriers to health care.
Primary Care Expand answer

Primary Care at Penn State Health Medical Group

Site mentors: Paula Sheaffer and Beth Weaver

Site description: Responsibilities include the following.

  • Participating in site huddles.
  • Completing home visits assessments.
  • Providing support to patients identified by primary care clinics.
  • Following up with patients.
  • Communicating with the team via the electronic medical record.
Physical Medicine and Rehabilitation Expand answer

Penn State Health Rehabilitation Hospital, 1135 Old W. Chocolate Ave., Hummelstown, PA 17036

Site mentors: Nancy Lokey (Physical Medicine and Rehabilitation nurse coordinator) and Wendy Baker (social worker)

Site description: Site experiences may include the following.

  • Meeting with multiple patients per session and providing means to ease transition from the rehab hospital to home.
  • Providing information to patients and caretakers on support groups, assistance programs, transportation, nursing programs and other community resources.
  • Acting as a conversational outlet for patients within the facility and at home.
  • Assessing the patient’s home environment.
Renal Dialysis Expand answer

Renal Dialysis, 200 Campus Drive, Suite 1400, Hershey, PA 17033

Site mentor: Gail Flannery (social worker)

Site description: Site experiences may include the following.

  • Sitting with a patient during a dialysis appointment.
  • Making home visits.
  • Scheduling or re-scheduling patient appointments.
  • Helping with transplant referrals.
  • Participating in multi-disciplinary rounds.
  • Discussing advanced directives.

Site-Specific Information: Non-Penn State Health Locations

Beacon Clinic Expand answer

Beacon Clinic for Health and Hope, 248 Seneca St., Harrisburg, PA 17110

Site mentor: Ruth Stoll (clinical coordinator)

Site description: Beacon Clinic for Health and Hope is a faith-based, free primary health care clinic serving the uninsured and underserved in the Greater Harrisburg communities. The clinic provides health education and the promotion of health and health care to adults 18 and older. Students assist patients by completing home visits with “no-show” patients and communicating their findings with the care team.

Geisinger Holy Spirit Expand answer

Geisinger Holy Spirit, 503 N. 21st St., Camp Hill, PA, 17011

Site mentor: Donna Hoak (director of care management)

Site description: Experiences may include working with the inpatient care management team and identifying patients who have frequent emergency room visits.

Lebanon Free Clinic Expand answer

Lebanon Free Clinic, 135 S. Ninth St., No. 2, Lebanon, PA 17042

Site mentor: Margaret Brandt (office manager)

Site description: Site experiences may include the following.

  • Physician shadowing.
  • Discussing nutrition with patients.
  • Helping patients who were previously identified by site mentor to access technology, find employment and access medical resources.
Lebanon VA Medical Center Inpatient Unit Expand answer

Lebanon VA Medical Center, 1700 S. Lincoln Ave., Lebanon, PA 17042

Site mentor: Dr. Michael MaCauley (physician)

Site description: Site experience may include the following.

  • Working with a veteran patient population.
  • Gaining insight into addiction and mental health issues.
  • Briefing with chief residents.
  • Identification of patients.
  • Exploring patient history.
  • Relaying patient concerns with level of care or financial/social barriers to the physicians.
  • Identifying common barriers to care: use of new/changing medications, completing follow-up care plans, recognizing need for changing living situations.
  • Working with care coordination referral team.
  • Understanding various models of health care systems and providing possible improvements.
Penn Medicine Lancaster General Health Care Connections Expand answer

Penn Medicine Lancaster General Health Care Connections, 555 N. Duke St., Lancaster, PA 17602

Site mentor: Dr. Jeffrey Martin (Care Connections physician); each student will be assigned to a patient navigator at Care Connections

Site description: Experiences may include the following.

  • Going on home visits (inner-city and rural environments).
  • Identifying barriers, which might include complex medical conditions, access to housing and access to food.
  • Developing intervention strategies, which might include pre-filled medication boxes from local pharmacies, ordering and servicing power chairs, acquiring patient access to Red Rose (local discount transportation company) and managing care with in-house care team.
WellSpan Sechler Family Cancer Center Expand answer

WellSpan Sechler Family Cancer Center, 844 Tuck St., Lebanon, PA 17042

Site mentors: Christina Ensinger (oncology social worker) and Vicki Fern (oncology nurse navigator)

Site description: Site experiences may include the following.

  • Making follow-up phone calls after appointments.
  • Performing home visits to assess and identify barriers to care.
  • Helping to schedule appointments.
  • Assisting patients with community resources.
  • Relaying patient concerns with level of care or financial/social barriers to the physicians and appropriate clinical staff.

Resources Patient Navigators Can Provide Patients

Assessing Available Community Resources Expand answer

When assessing resources, it is important for patient navigators to understand that resources change all the time. A resource that was available two months ago may no longer be available today. The resources listed on this page are updated as frequently as possible, but navigators should verify before providing any resource and assess resources themselves.

Understand the Community and the Issues

  • Review local data (poverty levels, mortality rates, etc.)
  • Talk to site mentors and medical team
  • Discuss resources with social workers, health educators, etc.
  • Contact people involved in the community

Be aware of local organizations

  • Churches
  • Food banks
  • Free clinics
  • Schools
  • Community centers
  • Local support groups

Search online and examine printed materials (merchandisers, newspapers, flyers, etc.) for upcoming events.

Develop a Resource Directory

  • Look for resources at the local, state and national level
  • Keep a resource book and share it with peers
  • Help to expand resources at the clinical site
General Resources Expand answer
  • APPRISE: APPRISE is a free, public program of the Pennsylvania Department of Aging that provides free health insurance counseling for patients with Medicare insurance to help them compare options. APPRISE counselors can help patients understand their Medicare benefits, their eligibility and enrollment, the Medicare appeals process, long-term care policies, etc.
  • Brain Injury Association of Pennsylvania: The mission of the Brain Injury Association of Pennsylvania is to foster a community of education, advocacy, supports and research to maximize the quality of life for those with brain injuries and their families.
  • Center for Independent Living of Central PA: This program provides services to people living with disabilities.
  • Central Pennsylvania Food Bank: Provides information on soup kitchens, food banks, etc., based on ZIP code.
  • Christopher and Dana Reeve Foundation: Provides resources and education for spinal cord injury and paralysis patients.
  • Eldercare Locator: This U.S. government service helps people find home and community-based resources for seniors.
  • Elder Helpers: Elder Helpers is a user-friendly, web-based service. Volunteers register to offer their services (transportation, grocery shopping, cleaning, cooking, etc.) based on their desire to help elders. The Elder Helpers program strives to safely and conveniently connect these dedicated, passionate volunteers with elders in their local communities. A $50 monthly donation to the organization by participants is required in order to request services.
  • GoodRx: This site allows users to compare prescription costs at local pharmacies.
  • Hershey-area lodging: This list includes many hotels in the Hershey area that provide discounts to families of Penn State Health patients, as well as special services like the American Cancer Society Hope Lodge and Ronald McDonald House.
  • LeadingAge PA: This is an association of not-for-profit services for senior citizens.
  • Mom’s Meals: This group provides high-quality meal solutions direct to the homes of seniors and patients nationwide. Customers choose every meal every order from a broad selection of entrees.
  • Needymeds: An organization that provides drug assistance, drug coupons for prescription and over-the-counter medications, disease-specific assistance programs on a national and state level, and a locator for free and low-cost dental and medical clinics within 20 miles of a patient’s ZIP code.
  • PACE and PACENET: These are Pennsylvania’s prescription assistance programs for older adults, which offer low-cost prescription medication to qualified residents 65 and older.
  • PAN Foundation: The PAN Foundation offers nearly 70 disease-specific assistance programs to help patients pay for their out-of-pocket costs, such as deductibles, co-pays and coinsurance, travel expenses and health insurance premiums.
  • Pennsylvania Department of Human Services: Human services information is available through the website and the helpline at 800-692-7462.
  • Pennsylvania Office of Vocational Rehabilitation: This program provides equipment, modifications and financial assistance with return to work or school.
  • Pennsylvania Waiver Program Independent Enrollment Broker: The Independent Enrollment Broker is a contracted statewide entity to facilitate and streamline the eligibility/enrollment process for applicants seeking services for several Pennsylvania waivers/programs.
  • Personal Care Homes guide: This resource was developed by the Pennsylvania Department of Human Services.
  • PillPack: This mail-order pharmacy packages pills in envelopes for each day and is accepted by many insurances.
  • Prevention Produce: This program is part of the Penn State College of Medicine group Food as Medicine, led by Dr. Danny George. It allows medical students to be matched with patients within Penn State Health who have been referred by providers and identified to potentially benefit from a nutrition intervention program. The program involves the medical student meeting with the referred patient at a local farmer’s market four times over the course of six weeks. Each meeting consists of reviewing a packet of themed nutrition education materials, followed by shopping together in the market. A large benefit of this program is the interaction between student and patient, from guided learning to healthy advice while shopping. Also, this program aims to aid in access to fresh produce, as each patient is given $10 to spend in the market, per family member, up to four family members. For details, email Anna Scipioni at ascipioni@pennstatehealth.psu.edu.
  • ProduceRX: Through this Penn State College of Medicine program, doctors, nurse practitioners and physician assistants prescribe fresh produce to patients who can use the prescription to get reduced-rate fruits and vegetables. Participating providers determine eligibility, with undeserved populations and high-risk patients for conditions like diabetes and heart disease being primary targets. A newsletter and videos provide recipes and tips to healthy eating. For details, email Marina Mizell at mmizell@pennstatehealth.psu.edu or Emma Baker at ebaker4@pennstatehealth.psu.edu.
  • QUAD Foundation: The QUAD Foundation is committed to assisting and supporting survivors of spinal cord injury resulting in quadriplegic paralysis.
  • Travis Roy Foundation: Provides services to those with spinal cord injuries and their families.
  • Tri-State Advocacy Project: Provides assistance with insurance denials and other community needs.
  • United Disabilities Services Home Assistance: UDS provides assistance with home modifications for those with disabilities and those who are elderly.
  • U.S. Department of Veterans Affairs: Provides resources for those who have served in the military and their families.
Dauphin County Resources Expand answer
  • Capital Area Coalition on Homelessness: Provides a variety of services, including lists of food, health and dental care options for homeless people.
  • Changing Hands: This program provides reuse for assistive technology equipment and will provide home assessments to determine what home safety equipment may be needed.
  • Dauphin County Area Agency on Aging: This county-based service provides assistance in the home, transportation, elder abuse resources, Meals on Wheels and health insurance counseling.
  • Dauphin County support groups: This list is compiled by Psychology Today.
  • LionCare: A free medical clinic run by students of Penn State College of Medicine at Bethesda Mission in Harrisburg. Call 717-257-4440, ext. 312 for details.
  • Salvation Army Compassionate Closure Program: Through this program, qualified patients can receive funds for a small funeral service, cremation and urn after death. The patient and family cannot have more than $1,800 in assets; they must be from Cumberland County or Dauphin County; and there are requirements about how the patient passed. All religions are accepted. For details, call 717-233-6755.
Lancaster County Resources Expand answer
  • Arch Street Center: Arch Street Center supports the recovery of adults living with serious mental illness by providing social, moral and material support, recreational and hygiene facilities and fresh, nutritious meals in a safe, nurturing environment.
  • Disability Empowerment Center of Lancaster and Lebanon Counties: DEC provides free and confidential services that prioritize self-determination, consumer control and personal choice to individuals of all ages, and with all types of disabilities.
  • Housing Development Corporation Mid Atlantic: This Lancaster-based group owns or manages more than 3,500 affordable rental homes in Pennsylvania, Delaware and Maryland serving 4,700 families, seniors and people with disabilities.
  • Lancaster City Housing Authority: LCHA provides affordable housing to eligible single people, couples and families within the City of Lancaster through more than 550 public housing units in six communities.
  • Lancaster County Behavioral Health and Developmental Services: BH/DS provides services to individuals with serious and persistent mental illness, children and youth with emotional disturbance, individuals with intellectual and developmental disabilities and children
    from birth to three years old who have developmenal delays.
  • Lancaster County Coalition to End Homelessness: LCCEH is a network of health and human service providers, business leaders and private sector individuals working to eradicate homelessness in Lancaster City and County through service coordination, advocacy, public education, and community organizing.
  • Lancaster County Council of Churches Food Hub: Food Hub provides fresh and healthy food to to 1,000 and more families a month.
  • Lancaster County Crisis Intervention: Crisis Intervention is a 24-hour emergency mental health service provided for persons experiencing anxiety, depression, suicidal or homicidal thoughts.
  • Lancaster County Drug and Alcohol Commission: This commission provide access to high-quality, community-based drug and alcohol prevention and education services for all citizens, and treatment services to uninsured and under-insured low-income citizens.
  • Lancaster County Office of Aging: Offers a variety of resources for senior citizens, including a list of senior centers.
  • Lancaster County support groups: This list is compiled by Psychology Today.
  • Lancaster Family YMCA Community Health Programs: The YMCA employs evidence-based programs that help people reduce their risk of chronic disease, better manage chronic conditions and reclaim wellness after illness.
  • Lancaster Housing Opportunity Partnership: This groups offers a number of housing programs and resources.
  • Love INC of Lancaster County: A network of more than 165 Lancaster County churches from 24 different denominations that allows individual congregations to meet the needs of the community by connecting caring church volunteers with people in need of their skills.
  • RASE Program of Lancaster: This program provides recovery coaching, recovery support groups, buprenorphine care coordination, annual events and all-day drop-in services for those recovering from addiction.
  • Red Rose Transit Authority: The Red Rose Transit Authority exists to provide effective public transportation services to the citizens of Lancaster County.
  • United Way of Lancaster County resource guide: Links to a variety of services are available. There is also a link to No Wrong Door, which offers information on adoption, children’s services, daycare, selecting a child-care provider, disaster/crisis, drugs and alcohol, education, the public library system, the public school system, finances, government, grief counseling, health, housing/home repairs, legal, local municipalities/points of interest, mental health, military resources, recreation/leisure, service organizations, social services, special needs, support groups, transition, transportation and volunteer opportunities.
  • Water Street Mission: Water Street Mission provides meals and shelter, as well as medical, dental, behavioral health, spiritual and career support.
Lebanon County Resources Expand answer
  • Community Health Council of Lebanon County: This group is a coalition of individuals and organizations working together to encourage and support a safe, healthy, and substance-free community for every individual with a focus on youth. It offers resources related to teen pregnancy, suicide prevention, tobacco use and more.
  • Compeer of Lebanon County: This program recruits, screens, trains and matches volunteers in one-to-one friendship relationships with adults who are receiving mental health treatment.
  • Disability Empowerment Center of Lancaster and Lebanon Counties: DEC provides free and confidential services that prioritize self-determination, consumer control and personal choice to individuals of all ages, and with all types of disabilities.
  • Jubilee Ministries Lebanon clothing store: 235 S. 12th St., Lebanon PA 17042
  • Juniper Village at Lebanon: Personal care living community at 125 Birch Road, Lebanon, PA 17042; 717-272-8782
  • Lebanon County Agency on Aging: Links to many different services in Lebanon county are available, including an eldercare daytime program, home support services, in-home care services, Meals on Wheels, senior community centers and more.
  • Lebanon County Christian Ministries: LCCM serves as the food and clothing bank for Lebanon County. Eligibility for food and/or clothing is based on need, not income. An interview of the family or individual is used to determine the need. Interviews are also used to determine if other services or referrals to other agencies could be provided.
  • Lebanon County Community Action Partnership: Services include child care assistance, transportation, case management, rental assistance, shelter assistance, bridge and transitional housing, shelter housing, information and referral, job readiness and life skills education.
  • Lebanon County Housing and Redevelopment Authority: This organization offers applications for low-cost housing, among other services.
  • Lebanon County Mental Health/Intellectual Disabilities/Early Intervention Program: This prorgam provides services to residents who have certain mental health diagnoses, a diagnosis of an intellectual disability or to children from birth to 3 years old who have the risk of developmental delay.
  • Lebanon Family Health Services: This program offers education, nutrition and reproductive health services to the uninsured and underinsured families of Lebanon County with emphasis on women, infants and children.
  • Lebanon Free Clinic: This clinic provides primary and behavioral health care to those living in Lebanon County who are uninsured. Doctors, nurses and support staff volunteer their time and provide health care services funded by donations.
  • Lebanon Valley Volunteers in Medicine: This free health clinic serves residents of Lebanon County, 18 to 64 years old, who are uninsured or underinsured.
  • Meals on Wheels: Meals are delivered to eligible persons age 60 and over who can’t afford or are unable to prepare meals. This program is offered through the Lebanon County Area Agency on Aging.
  • New Path Homeless Family Ministry (part of Jubilee Ministries): The New Path program offers shelter and in-depth care, including training and education, to men, women and children.
  • Salvation Army: 2211 E. Cumberland St., Lebanon, PA 17042 and 1031 Guilford St., Lebanon, PA 17046
  • Spang Crest: A Luthercare Community: Personal care living community at 945 Duke St., Lebanon, PA 17042; 717-274-1495
  • United Way of Lebanon County resource guide: Links to a variety of services are available. There is also a link to No Wrong Door, which offers information on adoption, children’s services, daycare, selecting a child-care provider, disaster/crisis, drugs and alcohol, education, the public library system, the public school system, finances, government, grief counseling, health, housing/home repairs, legal, local municipalities/points of interest, mental health, military resources, recreation/leisure, service organizations, social services, special needs, support groups, transition, transportation and volunteer opportunities.
Transportation Resources Expand answer

A number of transportation-specific resources are available for senior citizens and people with disabilities.