5 Target Services Log

HRSA Patient Navigator Demonstration Program

HRSA Patient Navigator Demonstration Program

Navigation Target Form (DRAFT)

Introduction to the Navigation Target Form

These are draft instructions. Do not train staff with this document until drafts have been finalized.

Revisions may be made to improve form/data entry screen layout and the clarity of instructions.

A final version of this document will be released no later than May 2011.

Suggestions for improvements are welcome.

The Navigation Target Form should be completed for each navigation target (e.g., referrals to care or other services). Data from all navigation targets need to be collected and reported to NOVA Research for inclusion in the data analysis. Collection of navigation target data should be initiated once the study database is online.

Using the Navigation Target Form. You are welcome to customize and otherwise modify the formatting of the Navigation Target Form. For example, you may choose to highlight options under required elements (categories) applicable to your site, or to delete those that are not applicable. However, you are responsible for the information on the form, so take care to avoid deleting required data elements. Since the data entry screen on the online database will mirror this data entry form, major changes are likely to cause increased data entry effort. If there is doubt about whether a specific modification may cause problems, please contact NOVA.

Study IDs. By the time the data system is online, NOVA will have worked with sites to determine the best strategy for assigning Study IDs to navigated patients. The process for linking patient information with the Study ID will need to be customized according to the data systems and data needs at each site.

Please email any questions or concerns regarding these instructions or the form to Debra Stark dstark@novaresearch.com and Caroline McLeod cmcleod@novaresearch.com.

Navigation Target Form (DRAFT)

Site use only: Local Identifier:

Study ID:

Subsite:

Status Date Identified: __ / __ / __ Date Scheduled: __ / __ / __  Not Available Date Attended: __ / __ / __  No Show  Canceled	Type of Service Check one Primary care Screening Specialist Specify, optional: Diagnostic service Clinical trial Behavioral health services Community organization Health care coverage Health education Pharmacy assistance Social services Other: Optional Coding:	Location Check one Internal External Optional Coding:
Status Date Identified: __ / __ / __ Date Scheduled: __ / __ / __  Not Available Date Attended: __ / __ / __  No Show  Canceled	Type of Service Check one Primary care Screening Specialist Specify, optional: Diagnostic service Clinical trial Behavioral health services Community organization Health care coverage Health education Pharmacy assistance Social services Other: Optional Coding:	Location Check one Internal External Optional Coding:

Instructions for Completing the Navigation Target Form (DRAFT)

These are draft instructions. Do not train staff with this document until drafts have been finalized.

Revisions may be made to improve form/data entry screen layout and the clarity of instructions.

A final version of this document will be released no later than May 2011.

Suggestions for improvements are welcome.

The data included on the Navigation Target Form should be collected every time a navigation target is identified. Navigation targets may include referrals to care, health education, and other services.

Local Identifier This item should be used to record whatever local identifier will be helpful to local staff; these data will not be entered into the study database.

Study ID Use this space to record the Study Identifier; this is the unique numeric ID assigned to each navigated patient.

Subsite If applicable, record the navigation “home” for the patient.

Status

Date Identified Record the date the navigator identified the need for this service/referral. An estimate is ok.

Date Scheduled Record the date when arrangements for the targeted service were scheduled. The appointment might be scheduled by the navigator or the patient. If the patient scheduled the appointment, enter the approximate date that the patient was successful in scheduling the appointment. NOTE: This is the date when the appointment was made; not the appointment date itself. If this information is not available (e.g., if the appointment was scheduled by the patient and could not be estimated), check the “Not Available” checkbox.

Date Attended Record the date that the patient received the targeted service. If the patient did not receive the service because they cancelled or failed to attend their appointment, check the appropriate box (i.e., “No show” or “Cancelled”).

Type of Service

Type of Service Record the type of service associated with this target record. If the patient was referred to a service that does not appear on the list, check the “Other” category and enter a description of the targeted service in the Other-Specify field.

Specialist-Specify (Optional) Record the type of specialist to whom the patient was referred. The online system will include a space in which to enter these data. This field is not a required component of the cross-site evaluation.

Optional Coding (Optional) Record any additional information that may be useful for local analysis. The online system will include a space in which to enter these data. Please do not include any information that might identify the patient (e.g., no patient or family names, addresses, or telephone numbers). This field is not a required component of the cross-site evaluation.

Location

Location Indicate whether the service will be provided within your organization or if the patient will be referred to an outside organization for services.

Optional Coding (Optional) Record any additional information that may be useful for local analysis. The online system will include a space in which to enter these data. Please do not include any information that might identify the patient. This field is not a required component of the cross-site evaluation.