A Guide to the Alzheimer’s Patient Navigation Model

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Alzheimer’s patient navigation models are a cost-effective, empathetic, and holistic approach to treating this disease. In this guide, we will talk about the benefits of this model.

Alzheimer’s disease has become a common ailment among older people that affects their memory. Nearly 6.2 mn Americans over the age of 65 have this disease. Degeneration and death of brain cells in old age causes Alzheimer’s. 

The affected individuals suffer from loss of immediate memory and confusion. The actual reason for such degeneration lies in the complex science of hormones. However, in this article, we will be focusing on handling the disease rather than the causes.

You might also be interested in reading about the foods that fight Alzheimer’s disease.

The popularity of the patient navigation program has increased over recent times as it fills numerous gaps in the current healthcare system. Many people are struggling to give the best affordable and equitable care for their elderly patients because the current system is both inadequate and ineffective outside the confines of the hospital.

A Guide To The Alzheimer's Patient Navigation Model

With the rise and high demand for health care providers, the patient navigator plays an integral part in helping provide patients and their families with better health outcomes.

There have been many changes and positive outcomes due to the patient navigation model in the health care system in recent years. These changes have given people affordable and accessible care services.

Chronic diseases like dementia and Alzheimer’s keep many troubling people as there is still no cure for them. Alzheimer’s patients need care that their families could not provide due to a lack of information about treatment. Healthcare trains community health workers as patient navigation to care for these patients outside the hospital, providing both physical support and advice to caregivers.

What is Patient Navigation?

It is a program that contains a separate community of care delivery agents. Most healthcare programs design a patient navigation model to promote access to timely diagnosis and treatment of chronic diseases like cancer and Alzheimers. 

Social workers who have knowledge from their own experiences with medical conditions and some community healthcare supporters receive training to help patients with empathy and understanding. 

The concept of private, one-to-one patient navigation helps reduce the problem of complex, costly, inefficient, and collapsed healthcare delivery systems in the country. Most patients, such as breast cancer patients or diabetes patients, can access cancer care among specific communities and populations across the country.

A Guide To The Alzheimer's Patient Navigation Model

History of Patient Navigation

The idea of the patient navigation model has a long history. At the start of the 20th century, this system became popular as a rising change for patient rights in the 1970s. 

Poverty, uneven access to medical care, discrimination, and cognitive impairment are the main factors that bring patient navigation to the fore. The National Welfare Rights organization united in 1972 to form a bill, which later became integrated and accepted by most health provider centers. 

  1. Harold Freeman

In 1990, Dr. Harold P. Freeman first pioneered the original concept of patient navigation. It was the first step to eliminate the barriers like poverty and discrimination to provide timely cancer screening, diagnosis, treatment, and supportive care among women who were experiencing breast cancer. 

Many citizens, workers, and individuals that served medical care under the minor communities find themself at risk due to financial communication, health care system, and cultural obstacles to care.

Patient Navigator Outreach

From 2005 onwards, policymakers came together to support the idea of private patient navigation, which made it popular as this model assists individuals in overcoming other barriers to care. 

The Act of 2005 brought about the Patient Navigator Outreach and CDPA

Under the leadership of Senator Robbert Menendez, the act was authorized with unanimous support. The health care system allocated grants to the program in 2010 for development. Over the next year, the government awarded $25 million to the centers that develop community-based navigation programs.

A Guide To The Alzheimer's Patient Navigation Model

According to the report, Dr. Freeman’s programs and other navigation programs proved valuable for many people, improving follow-up care and treatment. 

One more study shows a massive rise in five-year survival rates for breast cancer patients due to the development and improvement of the patient navigator program. 

Thanks to these positive outcomes, the other community-based navigator programs also had an opportunity to shine. 

How Does a Private Navigation Program Work?

In most cases, hospital-based nurses only manage the patient’s needs when they stay at the hospital. They work for the hospital and only refer to services within the limited system. But in a private navigator, the benefits are accessible anywhere without any boundaries. 

The private advocates work for the clients as they offer services to find the best resources and outcomes.

The concept of navigation or advocacy has developed far beyond cancer. However, it covers almost any work needed to help patients, care partners, and families find the right way through the healthcare system’s complicated maze.

A Guide To The Alzheimer's Patient Navigation Model

What Are The Principles of Patient Navigation?

The concept of patient-centric concentrates on the patient’s progress and continuum of medical care. Patient navigation needs principles that define the patient’s navigation or advocacy.

Healthcare Continuum

The Navigation program’s first duty is seamless healthcare across the patient’s “healthcare continuum.” 

The continuum of a patient begins in the neighborhood where they live and stretches to a medical center where doctors diagnose, detect any abnormality, and offer treatment, rehabilitation, and survivorship. 

A patient’s care needs to be delivered in a fragmented fashion because of chronic disease. A patient navigator creates a smooth and seamless flow for the patient’s journey through the healthcare continuum. 

The main function of navigation is to eliminate the barriers and help timely care of the patient’s treatment journey. One-on-one relationships between the navigator and the patient help effectively eliminate all obstacles. 

Clear Roles And Responsibilities

The navigator model should distinguish the role and responsibilities of patient navigation on the basis of practice and training from all the other providers. A navigation model should be integrated into the care provider team in the right way so that the patient can get maximum benefits.

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It is a function of navigation for making the care delivery services of navigators cost-effective. The health care system defines the service with the proper training required to navigate the patient through medical care and treatment.

Level Of Skill Decides Role

The level of skills and health care knowledge required by a navigator at the current navigation stage will decide the selected navigator’s role. 

The selection of navigators is dependent on the spectrum of navigation extending from respective services such as trained navigators, nurses, and social workers. This principle also applies to patients as healthcare provides them the care that requires their level of experience and education. 

This principle is also important to know at which point the navigation begins, including its ends in a given care system. 

Most Relevant For Areas Where Healthcare Infra Is Otherwise Poor

Care is urgently needed to navigate individuals in the area where the health care system is disconnected. It plays a part in connecting disconnected healthcare systems.

Navigation Coordinator

There is a need for coordination in the navigation system. When working in larger groups or systems of patient care, the navigation coordinator or manager can assign the coordination. A champion should be responsible for managing all phases of navigation activities.

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What is the Role of the Patient Navigation Model?

A patient navigation model for the patient has an essential part of complementing, supplementing, and extending healthcare providers’ treatment and outcomes by offering practical, social, and emotional support. 

Common Healthcare Services

In some cases, patient navigation, such as social workers help people with simple tasks such as providing common health care services and encourage participating in community advocacy activities.

Insurance Awareness

They also provide secure insurance options for health care services that many people are unaware of. These tasks are beyond the scope of principles of patient navigation but are essential for the populations that navigators serve and the healthcare center where they work.

Elderly woman dancing in a wheelchair

Fill Gaps In Healthcare System

Navigators fill the gaps between separate healthcare systems. They also help complement and enhance the role of caregivers by supporting and helping each other to implement and sustain needed health behaviors.

What are Common Patient Navigator Models? 

With the proper training and practice from the health care system, a person can become a patient navigation model. However, there are different patient navigation models, some common models include:

Support Groups

Support groups are a gathering of different people from the community who share common experiences, conditions, and similar situations. Generally, these gatherings contain people who are able to mutually provide emotional and practical support to each other.


The professional patient navigation model is people who share the same experience and are brought together with the help of a healthcare system or team. The professionals are able to address their self-management challenges.

Elderly woman walking with her caregiver

One On One Support

One-on-one individuals support the person with the condition on a one-on-one basis. They deliver support by phone or face-to-face meeting. This method offers great opportunities to approach a very unsocialized person tailored to a client’s needs. 

This type of navigator is often used when a program targets individuals with high needs, especially those who require intense intervention with their healthcare provider.

Family To Family

One-to-family, or family-to-family support model, they provide support to the family of the patient. In some cultures where family values and relationships are extremely crucial, the patients require this family support, and the model provides it by home visits. 

Tele Support

Telephone-based navigation model, they support the patients and their families through regular phone calls.

  1. Mobile phone-based patient navigators support the patients and their families through a combination of text messages and phone calls.
  2. Web and email-based patient navigators provide support to the patient via internet-based communication through e-mails. 

Patient Navigation Model For Alzheimer’s – How A Navigator Can Help

Starting the conversation

When someone first develops the early symptoms of Alzheimer’s, the person can find it difficult to tell if anything is wrong. This problem is a severe obstacle for the affected person and the family. 

They are reluctant to begin conversations with their doctor as they are afraid of leading the discussions. A patient navigator can be useful at these times by starting the conversations with ease and more comfortably as they provide their full support and education. 

A Guide To The Alzheimer's Patient Navigation Model

They can help individuals outline the best way to take advantage of the healthcare provider’s resources and offers. With the initial conversation, the patients and caregivers feel empowered.

Ensuring of the initial conversation

Moreover, patients with Alzheimer’s Disease and their families find it difficult to communicate effectively with healthcare providers.

A patient navigator can help in this matter as they can speak with the person diagnosed with Alzheimer’s and their family before the consultation with their healthcare provider. The preliminary talks can set the foundation for candid, valuable conversation, and they can also set required expectations for the patient’s visit with the doctor.

With this method of navigation, patients and their families will feel more confident following the first conversation with the healthcare provider team. It also boosts their confidence level as they can work with a health care team over the entire course of treatment.

Ensuring a timely diagnosis

After the initial consultation, the primary care health care provider will give a suggestion of a specialist and refer to additional testing. The task gives great anxiety and logistical hardships that can cause difficulties in arranging schedules, insurance coverage, and more obstacles.

A patient navigator can help with a person’s schedule and insurance. They can help discover the right site of care to complete the particular needs of the Alzheimer’s patient. Providing resources and helping calm the anxiety during the interim period is the duty of the patient navigation model.

A Guide To The Alzheimer's Patient Navigation Model

With navigation, the Alzheimer’s patient will follow through with a referral that their healthcare provider suggests. Also, it provides timely specialist consultation.

Coming to unfamiliar terms with a diagnosis

After the person is diagnosed with Alzheimer’s, both the patient and their family come with numerous questions. These questions increase as the period of diagnosis moves forward. The patient and family research online for Alzheimer’s Disease and talk to others in their community.

A patient navigator can provide enough information on a particular subject and answer the questions right after the diagnosis of dementia and in the following weeks. The patient navigator can talk about these diseases and their treatment in order to support the healthcare guidelines.

The core role of the patient navigator is to help and support the patient with their treatment. Specifically, they fulfill the part of the care team, such as nurse and caregiver. Generally, throughout Alzheimer’s disease, the patient requires regular appointments with their doctor to see the progress, work with their symptoms, or detect any change in behavior or function. 

The navigator also helps to ensure the patient and family understand all options and can access the right medications or recommended support.

Providing information and resources

A huge amount of information and educational material is available about the science, care, and treatment of Alzheimer’s disease. However, these materials may not be useful as they are overwhelming, contradictory, and sometimes unreliable. 

Without the knowledge of care and services, the patient and family will face many hurdles accessing them. A patient navigator can find and organize the materials. They provide accurate and appropriate information that lays out best practices. 

A Guide To The Alzheimer's Patient Navigation Model

They can address barriers like financial support by understanding the insurance requirements. They also address the lack of insurance and lack of access to care services and help facilitate more efficient care through the care continuum.

With a navigator, the patient can utilize the existing information material.

Arranging and managing treatment and expectations

Many patients and their families think that the medication is not working and fear its side effects outweigh the benefits. Without the proper medication, the cognitive ability of patients will start declining, which can discourage their family and create a situation where they can’t think what to do.

A patient navigator can set and manage expectations from an ongoing treatment phase. The patient navigation model can also provide guidance aligned with and informed by the patient’s health care provider. 

They support and provide directions on non-pharmacological management techniques, including exercise, diet, education for family, and social interaction.

With navigation, the person with Alzheimer’s and the family can explore the options and come to an end to make the right decisions about the treatments. And navigator ensures that the patient adheres to the course of the entire treatment directed by the healthcare team.

Identifying the right option for care

It is hard to find the appropriate option for patients with Alzheimer’s and their families in the numerous options. It is also difficult to understand what options can help secure support and care needed along the patient’s journey.

Patient navigation can provide a solution to this obstacle by counseling patients and families through the options for care. They show the connection of these services with different organizations that provide them. Navigation models can help patients make the right financial decisions with assisted living care, in-home care, etc. 

A Guide To The Alzheimer's Patient Navigation Model

Moreover, the navigator can help patients and families understand the dynamics involved, including socialization, independence, medical attention, etc. the navigation models are also a connection between the support groups and advocacy organizations for the patient.

With the help of a patient advocate or navigator, the patients and their families can understand and connect with the third wheel, such as caregiver organizations, support groups, or providers.

Caring for the caregiver 

In some unfortunate cases, the caregiver experiences their health issues. The stress and demand to play this role can affect the health of navigators. Caregivers often have neither energy nor time to proactively seek professional medical help for themselves. Caregivers need to maintain a healthy routine and care for themselves. 

A patient navigator helps guide a patient’s caregiver to make the right decisions about their own body and health. They also support caregivers with non-health demands, including financial planning, work, and legal issues. They are also a connection between families and resources that they need to manage for the complex treatment.

This service, especially for the caregiver, can enjoy good health without bearing a care burden alone.

The Checklist of Alzheimer’s Patient Navigator

Identify and train the navigator.

It is vital for the navigator to fully understand the inner workings of the healthcare system, including the complex set of affairs and medical procedures that the patients require after diagnosis. 

Due to the scarcity of medical treatment options, Alzheimer’s is complex and different from other diseases. In conclusion, the ideal patient navigation model for the Alzheimer patient must understand how to manage the healthcare system. 

Also, the navigator is skilled and capable of connecting and working with third parties, especially outside the clinic organizations. The healthcare system gives training to navigators in order to achieve these skills. Only a train navigator can provide both options. 

A Guide To The Alzheimer's Patient Navigation Model

Secure funding

Patient navigator for cancer has received a wide range of funding from both private donors and public organizations. These organizations believe in patient navigation and prove it fruitful in securing initial funds for Alzheimer’s patient navigation. 

For Alzheimer’s patients, there are some options, including National Institute on Aging (NIA) and the Center for Medicare and Medicaid Services (CMS). 

Learn best practices

Many social workers can learn patient navigation at patient navigation centers in oncology. They teach best methods, practice, and training curricula. The Harold P. Freeman Patient Navigation Institute, is one of the best patient navigation centers.

Embed patient navigation within quality measure work

Center for Medicare and Medicaid Services defines measures as tools that help healthcare providers measure medical care processes, expectations, and patient perceptions. The quality measure also includes safe, effective, efficient, patient-centered, and timely care.

The healthcare system migrates to a more outcomes-based system that helps patient navigation integrate into the migration within Alzheimer’s care and treatment.

Pilot programs

Pilot programs can test the right patient navigation model for Alzheimer’s patients. These programs provide lessons to shape future navigation models. Experts believe CMS could be a strategic pilot program.

Link to other innovative programs

An ideal care partner must be capable of connecting to innovative programs that help patients meet their health care needs in the community. The care partner also avoids becoming a burden to nursing homes or other care facilities. Patient navigation should be able to cooperate with other parties such as financial and other support organizations.

Patient Navigators Are Crucial To Alzheimer’s Treatment

We hope that this guide offers valuable resources and information that help people seeking a care provider-developed navigation program. After reading this document, we hope that people will become familiar with who are patient navigators and what they do. 

A navigator or patient advocate provides effective and affordable care to people to get better health outcomes. The clinical care program paired social workers and community health workers to deliver navigation services.