Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient -centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.
Evidence of participation in a Patient Navigator Program (PNP), including engaging with Community Health Workers or Promotoras, designed to assist patients with communicating with health care providers regarding their questions, obtain information about their procedures/treatments and arrange for test or appointments. PNP should take into account patients' language and communication preferences, literacy level, and cognitive and physical disabilities.
1) Documentation of evidenced-based resources and tools to reduce avoidable hospital readmissions; and
2) Utilization of a patient-centered and team-based approach leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful; and
3) Implementation of systems, tools and strategies that encourage a more supportive recovery period.