Organizations with effective patient navigator programs emphasize the importance of tailoring a program to the unique needs of the organization and the patients served. So what do you do if you are implementing a patient navigator program across a network of providers? In 2009, the New York City Department of Health and Mental Hygiene, with Ryan White Part A funding, began implementing a Care Coordination program with patient navigation as the cornerstone of the model. Over three thousand patients maintain active enrollment across 28 agencies (approximately 50 sites). While there is a standard protocol for patient navigation services, there is also room for flexibility since the providers vary widely. There are hospital-based programs as well as community-based organizations. The Care Coordination program, which is designed to link clients to care and keep them in care, is based partially on a community health worker model with the navigator integrated into the care team.

The patient navigators are key players on the care team and have the most interaction with clients. While patient navigators must reflect the community they serve, they are not necessarily people living with HIV. Services provided include health promotion (a comprehensive curriculum with 16 modules), basic case management services, and accompanying clients to their various appointments. Patient navigators may follow up with patients in their homes and can even provide directly observed therapy (DOT) to ensure that clients adhere to their medications. Depending on the needs of the clients they serve, caseloads can vary from 14 to 20 clients per patient navigator. Some agencies have DOT specialists who each serve as few as seven clients.

Despite the diversity of agencies, the Department takes steps to standardize patient navigation services. There are suggested job qualifications and a job description. There is also a standard protocol for patient navigators. The protocol includes requirements for training for new staff and existing staff and ongoing clinical supervision.

Because health promotion is such an integral part of the model, the Department conducts training of trainers with agency staff to support their Care Coordination teams in the health promotion curriculum. Each agency has at least two staff (e.g., program director, care coordinator, or patient navigator) trained in the health promotion curriculum. The trainers then conduct health promotion training at least bi-monthly with all Care Coordination staff at their agency.

An essential element of the Care Coordination program has been the provision of ongoing technical assistance to network agencies. One of the most important areas for technical assistance has been field safety, since field work is new for many agencies. In addition, as navigators worked with clients it became apparent that they needed additional training in the areas of substance abuse and mental health. Navigators have required training around cultural competency, including LGBT issues and they have benefited from training in program administration skills such as data entry. Project Officers from the Department also work one-on-one with agencies in response to specific program needs.

The Department uses various measures to evaluate the effectiveness of navigators. Quantitative data are collected on a variety of indicators such as the number of home visits or educational sessions. The surveillance registry is used to conduct outcome evaluation, using indicators such as viral load or CD4 count. Care Coordination services are also assessed in client satisfactions surveys, which rank it very high.

Introducing patient navigators into the medical care team has involved a major cultural shift for many agencies. During the initial implementation, to ensure buy-in, the Department devoted significant time to educating medical providers about the role of the navigator. Medical providers quickly saw the benefits of the program in terms of increased patient engagement in care. Agencies have also had to be flexible in implementing the model. Some patients require much more support than others, which affects in caseload size. In addition, much "legwork" is required for successful navigation. Navigators are often out in the field, which may not always translate into a lot of contact with the client. However, the effort is appreciated by clients. When navigators do home visits, if they do not connect with the client they leave a note. Anecdotally, clients have reported that the level of interaction they have with navigators motivates them to remain in, or in some cases, come back to care. While it may be labor intensive, the results warrant the effort. Newly diagnosed patients enrolled in these services are roughly 25% more likely to be retained in care and roughly 50% more likely to achieve viral suppression than newly diagnosed patients not enrolled in these services.