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Patient Navigator Project for At-Risk and High-Risk Diabetes Patients
Lutheran Family Health Centers of Lutheran Medical Center 
6025 Sixth Avenue
Brooklyn , New York 11220
Project Director: Kathy Hopkins
This patient navigator project will build on the services provided to high risk diabetic patients by Lutheran Family Health Centers' existing Care Management program, which has utilized a community health worker and care management framework to serve adults and children with diabetes and cardiovascular conditions.
A high proportion of the project's target patient population is culturally, linguistically and socio-economically marginalized, resulting in significant barriers to accessing adequate care to effectively managed their diabetes.
The patient navigators hired for this project will help high risk patients access quality health services, embrace positive health behaviors, and navigate complex treatment regimens.
Hired because of their unique access to Southwest Brooklyn communities and the trust they enjoy with community residents, Patient Navigators will be able to integrate health information about prevention/management of disease and the health system into the community's culture, language, and value systems.
The Patient Navigator model has been found particularly effective in programs that seek to create positive change in health seeking behaviors among vulnerable and underserved populations, such as the one served by Lutheran Family Health Centers.
The Patient Navigator program will serve the medically underserved, ethnically diverse contiguous southwest Brooklyn neighborhoods of Sunset Park, Bay Ridge, Dyker Heights and Bensonhurst, where approximately
- 25,000 individuals have diabetes,
- 59,000 individuals are obese and
- 74,000 have high blood pressure.
Obesity and high blood pressure are two obvious risk factors for type II diabetes.
Of particular concern is the apparent rise in the prevalence of childhood diabetes in the target population. The appearance of a spike is consistent with recent projections by the Centers for Disease Control and Prevention that one in three children born in the U.S. in 2001 is expected to become diabetic, with even worse outcomes for Hispanic and Asian children
The Patient Navigator program will employ seven patient navigators to serve an anticipated 650 patients belonging to two high risk cohorts:
- Adult diabetics with an A1c value > 9.0 and
- Children with a family history of diabetes and a probable diagnosis of obesity.
The primary goals of this project are to
- eliminate barriers to care,
- ensure timely delivery of services and
- reduce the morbidity and mortality associated with diabetes among this high-risk patient population.
The program will partner with Columbia University's Mailman School of Public Health and the 1199 Training Fund to train patient navigators and to evaluate the outcomes of the project.
Page last updated: October 8, 2008
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