Key messages
• People who receive community care navigation assistance are probably slightly less likely to be admitted to hospital for unplanned reasons in the first year after care navigation than those who do not receive this type of assistance.
• We need more studies, with better reporting, to identify the types of people, settings and ways of delivering community care navigation that are likely to deliver the most benefit and to understand the impact on patient-reported health outcomes.
What is community care navigation?
Community care navigation is when a third party, usually a trained clinician, guides and supports an individual in accessing the care provided by multiple healthcare and service providers, but is not directly involved in delivering clinical care. Care navigators proactively guide patients through often complex healthcare systems, aiming to help them receive timely health care and foster self-management and autonomy through education and emotional support.
Why is this review important?
As people age, they often develop chronic health conditions (long-lasting illnesses that persist for more than a few months) that can lead to frequent use of hospital services, resulting in increased burdens on health systems globally. Those with complex chronic health conditions are more likely to report having unmet health and care needs, leading to frequent use of hospital services. Preliminary evidence suggests that community care navigation may improve a person’s access to community-based services, reducing unmet healthcare needs and leading to a reduction in hospital admissions and emergency department attendances. Further evidence is needed to confirm this.
What did we want to find out?
We wanted to find out if delivering care navigation in the community reduces unplanned hospital presentation rates (hospital admissions and emergency department presentations) and improves patient-reported health outcomes, including health-related quality of life, in groups considered to be at risk of hospitalisations.
What did we do?
We searched for studies where participants received either an intervention that met our definition of community care navigation or usual care – routine medical care for preventing and treating diseases. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We included and analysed 19 studies, involving 36,745 people. All studies were conducted in high-income countries and funded by medical research institutes or universities. Five studies focused on populations with multiple chronic conditions; of these, three used hospital data systems to identify at-risk populations based on a range of characteristics. Four studies were conducted in a community clinic and the other 15 studies were initiated in a hospital but delivered in the community. Seven studies used a registered nurse as the care navigator, five used social workers, and one used community health workers. Six studies used multidisciplinary teams. Multiple components of care navigation were offered across the studies, including screening, needs assessment, navigating care and services, developing care plans, and follow-up phone calls. Telephone follow-up was the most common method of communication in the studies.
Main results
• Compared to people who received usual care, those who received community care navigation were slightly less likely to be admitted to hospital for unplanned reasons in the year after receiving care navigation.
• Compared to usual care, community care navigation may make little to no difference to the number of people admitted to hospital for unplanned reasons in the first month, but the evidence is very uncertain.
• Compared to usual care, community care navigation probably results in little to no difference in the rate at which people presented at the emergency department, both in the first month and the first year.
• Community care navigation compared to usual care increased the proportion of participants having outpatient appointments in the first month, which may indicate that community care navigation helps shift patient care towards community services.
• Further studies are required to reliably understand the effects on patient-reported health outcomes, treatment satisfaction and quality of care.
What are the limitations of the evidence?
We are confident that community care navigation increased outpatient appointments in the first month, compared to usual care. Our confidence in the evidence for the other outcomes ranged from moderate to very low. Due to the nature of the intervention, it was highly likely that people in the studies were aware of which treatment they were receiving, which could have influenced how they reported outcomes, such as patient-reported health outcomes. There were also wide variations in the types of outcomes reported and the time periods during which they were measured.
Further research is required to understand the effects of community care navigation programmes beyond 12 months, patient-reported health outcomes in this area of research, and which aspects of community care navigation are most effective. We plan to involve patients and members of the public in future updates of this work to help us interpret the results.
How current is this evidence?
The evidence is current to October 2024.
Community care navigation for people at risk of unplanned hospital presentations is likely to reduce hospital admission rates within 12 months (365 days) and increase outpatient appointments within one month (30 days) compared to usual care, with moderate to high certainty of evidence. Results showed little to no effect on hospital admissions within one month (30 days) or on emergency department presentation rates compared to usual care. The evidence is very uncertain about the effect of community care navigation on health-related quality of life and quality of care. More robust studies are required to produce greater evidence certainty. Study risk of bias can be improved if future studies use traditional RCT designs and implement strategies to reduce dropout rates and reduce missing follow-up data.
Care navigation is a type of care co-ordination used to manage people with chronic conditions with the goal of reducing unplanned hospital presentations and improving patient care and outcomes. Care navigation involves individual case management by a trained professional who is not involved in the person’s direct care. Care navigation has been used in various healthcare settings, adopted as a single or multi-component intervention by different health services. However, little is known about its effect on unplanned hospital presentations and patient-reported outcome measures (PROMs).
Primary: to assess the effects of care navigation, delivered in the community, on hospital presentations and patient-reported outcome measures in people at risk of unplanned hospital presentations.
Secondary: to assess whether the effects of community care navigation differ according to the type of clinician delivering the intervention and the populations receiving the intervention.
We used CENTRAL, MEDLINE, four other databases and two clinical trial registers, together with reference checking, citation searching and contact with study authors to identify the studies included in this review. The latest search date was October 2024.
We included randomised controlled trials (RCTs) and cluster-RCTs that recruited people who were at risk of hospital admission and utilised care navigation delivered in the community as an intervention. The comparison was usual care.
Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We performed a meta-analysis of the results where possible, and a narrative synthesis of the remainder of the results. We present results in a summary of findings table, showing effect sizes for all outcomes.
We included 19 studies (36,745 participants), all conducted in high-income countries. Eighteen were RCTs. Of these, four studies were pragmatic non-blinded RCTs that randomised participants prior to obtaining consent. One study was a cluster-RCT. Follow-up ranged from one to 24 months.
All studies included various healthcare professionals as care navigators: registered nurses in seven studies, social workers in five, and community health workers in one. In six studies, a multidisciplinary team delivered the care navigation intervention. The studies investigated the effects of community care navigation interventions in a variety of groups, including older people, those with chronic diseases (such as heart failure, chronic obstructive pulmonary disease, diabetes, mental health problems, cancer, alcohol and other drug use), people with complex psychosocial needs, high readmission risk and frequent emergency department users. All studies compared the intervention to usual care.
Across the five risk of bias domains and where outcomes were reported, we deemed three of 42 study results to have 'some concerns' in at least one domain. Overall risk of bias across all domains ranged from 'low risk' in results reported in two studies to 'some concerns' or 'high risk' of bias across all other results. Overall, when inconsistency was also considered, we judged the certainty of the evidence to be very low or moderate.
There may be little to no difference in unplanned hospital admission rates within one month (30 days) between community care navigation and usual care, but the evidence is very uncertain (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.79 to 1.14; P = 0.59; 5 studies, 3488 participants; very low-certainty evidence). However, community care navigation likely results in a reduction in unplanned hospital admission rates within 12 months (365 days) compared to usual care (RR 0.87, 95% CI 0.77 to 0.97; P = 0.01; 3 studies, 795 participants; moderate-certainty evidence). Community care navigation probably results in little to no difference in emergency department presentation rates within one month (30 days) compared to usual care (RR 1.09, 95% CI 0.92 to 1.29; P = 0.30; 3 studies, 4087 participants; moderate-certainty evidence) and in emergency department presentation rates within 12 months (365 days) (RR 0.99, 95% CI 0.91 to 1.08; P = 0.88; 2 studies, 873 participants; moderate-certainty evidence). None of the studies measured hospital presentations within three months (90 days).
Eight studies reported different types of PROMs, collecting results at different time points. We narratively synthesised these results in the main text of the review, but could not determine the impact of community care navigation on PROMs due to the very low-certainty evidence.
Community care navigation increases the proportion of patients having hospital outpatient appointments within one month (30 days) (RR 1.07, 95% CI 1.01 to 1.13; P = 0.02; 2 studies, 2178 participants; high-certainty evidence) compared to usual care, which may indicate that the intervention shifts patient care towards community services. We could not determine the impact of community care navigation on general practitioner (GP) visits, treatment satisfaction and quality of care due to the low- or very low-certainty evidence. No included study measured adverse events.