Evidence map›Paper›PMID 41645076›Full record

Observational studyBMC geriatrics2026

Implementation of a peer health navigator program for patients at risk of frequent hospitalisation.

Rebecca L Jessup, K Stockman, D Nguyen, C Haywood, M Suleiman, S Thomas, Johanna Hayes, Anne-Marie Fabri, D Campbell

Abstract readObservational Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in BMC geriatrics, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing 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

1 citing paper in PubMed.

  1. Article
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

9 authors.

Rebecca L JessupSchool of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Melbourne, Australia. Rebecca.jessup@nh.org.au.
K StockmanStaying Well and Hospital Without Walls Program, Northern Health, Epping, Melbourne, Australia.
D NguyenFaculty of Art, Design and Architecture, Monash University, Clayton, Melbourne, Victoria, Australia.
C HaywoodAustin Health Department of Medicine, Austin Health, Heidelberg, Australia.
M SuleimanOffice of Research, Northern Health, Epping, Melbourne, Australia.
S ThomasStaying Well and Hospital Without Walls Program, Northern Health, Epping, Melbourne, Australia.
Johanna HayesStaying Well and Hospital Without Walls Program, Northern Health, Epping, Melbourne, Australia.
Anne-Marie FabriStaying Well and Hospital Without Walls Program, Northern Health, Epping, Melbourne, Australia.
D CampbellStaying Well and Hospital Without Walls Program, Northern Health, Epping, Melbourne, Australia.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundIndividuals at risk of frequent hospitalisation often experience complex health and social challenges. Peer health navigation programmes have emerged as a promising strategy to support these patients, improve continuity of care, and reduce hospital use. The strategy has strong alignment with the transition of care management model.

objectiveTo describe the baseline demographic characteristics, self-reported health status, and frailty of patients enrolled in the Northern Patient Watch (NPW) program. NPW employs peer health navigators, under the supervision of health professionals, to support individuals at high risk of recurrent hospital admissions.

methodsThis observational study examined all patients who enrolled in the NPW programme between November 2021 and October 2024. Baseline data were collected on demographics, health-related quality of life (EQ-5D-5 L), and frailty (Rockwood Clinical Frailty Scale). Descriptive statistics were used to summarise the findings.

resultsA total of 650 patients were enrolled. The mean age was 70 years, and 56% were female. One-third lived alone, and 29% spoke a language other than English at home. The mean EQ-5D-5 L index score was 0.72, with a mean EQ-VAS of 58.9, indicating moderate health-related quality of life. Moderate issues were frequently reported across all EQ-5D-5 L dimensions, particularly in mobility, pain, and mental health. Two-thirds of participants were classified as vulnerable or frail.

conclusionPatients who enrol in peer health navigation programmes such as NPW are typically older adults with moderate but not severe health challenges. These individuals may be particularly well positioned to benefit from early, tailored support that can prevent further deterioration. Findings highlight the potential value of peer navigation programmes in engaging at-risk populations before health crises occur.

Indexed as

HospitalizationPatient NavigationPeer GroupAgedAged, 80 and overFemaleFrail ElderlyHumansMaleMiddle AgedQuality of LifeFrailtyFrequent hospitalisationHealth-related quality of lifeOlder adultsPeer health navigationTransitional care

Identifiers

PMID41645076
PMCPMC13081406

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LicenceCC BY
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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.