Tompkins County program was designed as a stand-alone effort in collaboration with Cayuga Medical Center. In Albany County, the Navigator program was a supplement to the 30-day CTI being implemented by Northeast Health in Albany Memorial and Samaritan Hospitals with the intent of looking at both 30 and 90- day outcomes. The volunteer provided guidance and assistance with non-medical tasks following discharge and provided patients and their families with the knowledge and awareness of available services in their community.
In the Albany County Project less than 9% of patients who agreed to participate in traditional care transitions were readmitted to the hospital in 30 days; five of those who participated in the Navigation were readmitted within 30 days and all ten within 90 days. A review of patient data confirmed that the Navigation participants were more frail at baseline than the general care transitions participants
In the Tompkins County Project all twelve participants completed a Navigation-only intervention and all 10 avoided readmission at 30 days and at 90 days.