Community Linkage Through Navigation to Reduce Hospital Utilization Among Super Utilizer Patients: A Case Study.

This paper describes a program model that uses hospital- and community-based patient navigators and social workers to link super utilizers of the hospital system with existing community resources to improve access to services and appropriate care while lowering hospital utilization. A case study is used to illustrate a typical super utilizer patient who is homeless and has psychosocial issues. The navigator's and social worker's roles and approaches are described, and specific community linkages for this case are listed.