Evidence map›Paper›PMID 41578326›Full record

ArticleBMC health services research2026

A qualitative study exploring a community health navigator intervention for patients with chronic and complex care needs transitioning from hospital to home.

Jacqueline Ramirez, Sharon Parker, Carole Bandiera, Parisa Aslani, Anthony Brown, Fiona Doolan-Noble, Sara Javanparast, Fiona Haigh, Regina Osten, Sarah M Wright and 3 more

Abstract read
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Article in BMC health services research, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

0numbers the graph read from it
0cells of the map it votes in
0citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

0 citing papers in PubMed.

No citing paper in PubMed yet.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

13 authors.

Jacqueline RamirezInternational Centre for Future Health Systems, University of New South Wales, Kensington, NSW, Australia. jacqueline.ramirez@unsw.edu.au.ORCID http://orcid.org/0000-0002-9034-328X
Sharon ParkerInternational Centre for Future Health Systems, University of New South Wales, Kensington, NSW, Australia.
Carole BandieraSydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.
Parisa AslaniSydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia.
Anthony BrownHealth Consumers New South Wales, Sydney, Australia.
Fiona Doolan-NobleGoldfields University Department of Rural Health, Kalgoorlie, WA, Australia.
Sara JavanparastCollege of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.
Fiona HaighInternational Centre for Future Health Systems, University of New South Wales, Kensington, NSW, Australia.
Regina OstenNew South Wales Agency for Clinical Innovation, Sydney, NSW, Australia.
Sarah M WrightInternational Centre for Future Health Systems, University of New South Wales, Kensington, NSW, Australia.
Ben Harris-RoxasSchool of Population Health, University of New South Wales, Kensington, NSW, Australia.
Debra DonnellyAged Health, Rehabilitation and Chronic Care, Sydney Local Health District, Sydney, NSW, Australia.
Mark F HarrisInternational Centre for Future Health Systems, University of New South Wales, Kensington, NSW, Australia.

Funding

National Health and Medical Research Council funded partnership grant (Grant number: APP1196912) including Sydney Local Health District, Central and Eastern Sydney Primary Health Network, New South Wales Agency for Clinical Innovation and Health Consumers New South Wales. APP1196912
6 · The paper itself

Abstract

backgroundCommunity Health Navigators (CHNs) can promote healthcare access and care coordination. However, little is known about the experiences of stakeholders when CHNs are embedded within a multidisciplinary care team setting. The CHN role aimed to improve the transition from acute care to home for patients with chronic conditions, through linkage to general practitioners, other professional follow-up, and social and community supports.

methodsThree CHNs were employed and located in an Aged Health, Rehabilitation and Chronic Care outreach team in Sydney, Australia. This qualitative study aimed to explore the perceptions of patients, healthcare professionals (HCPs), and CHNs about the support provided, and to determine what factors supported or impeded the CHN role in this setting to inform implementation in the Australian context.

resultsTwenty semi-structured interviews with twelve patients, five HCPs and three CHNs were analysed inductively using interpretive thematic analysis. Three key themes were constructed: operationalising CHN integration into the team setting; contributions to support the needs of patients post-hospitalisation; and, experiencing the emerging navigation role. Timely emotional, informational, and practical support provided during the transition period were highlighted. The healthcare team viewed the CHN as valuable to support patients non-clinical needs and patient management. The interface between the clinical focus of the team and the non-clinical nature of the role was challenging. Supportive supervision was essential to support knowledge, problem solving, and to promote acceptance within the team.

conclusionsThe findings suggest CHN roles can offer a ‘safety net’ for transitioning patients. Integrating this role within a complex clinical care setting requires time, organisational commitment, and policy and guidelines to address the interface with other professional healthcare roles. Promotion to patients, clinicians, and other service providers is required to improve awareness of the CHN role. TRIAL REGISTRATION NUMBER: Trial registration number: ACTRN12622000659707. Date of registration: 5 May 2022.

Indexed as

Community Health ServicesContinuity of Patient CareHome Care ServicesPatient NavigationAgedChronic DiseaseFemaleHumansInterviews as TopicMaleMiddle AgedPatient Care TeamQualitative ResearchCare coordinationCare transitionsChronic conditionsCommunity health navigatorsHealthcare accessPost-hospital dischargePost-hospitalisation

Identifiers

PMID41578326
PMCPMC12911041

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LicenceCC BY-NC-ND
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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.