Long COVID Patient Navigation Model

Describes how clients become aware of the program, access a referral and enroll in the navigation program.
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Establishes a quantitative starting point before navigation begins. Captures baseline levels of access to care, confidence navigating the healthcare system, goals, quality of life (best days and worst days), participation in daily activities, employment status, and return-to-work readiness. Completed using questionnaires and surveys (i.e. Likert Scale)

This is where the client shares their story, experiences, and current barriers. Individualized goals are collaboratively set with the patient navigator and trust, validation, and emotional safety begin to be established.

Assesses change over time by re-administering baseline measures to evaluate quantitative outcomes, inform program effectiveness, and support evaluation and funding efforts.

A reflective conversation where the client shares feedback on their navigation experience, including satisfaction with the program, their Patient Navigator, the quality of guidance received, follow-up support, and progress towards their goals (e.g. how many goals were met).

A structured transition informed by clients’ goals and progress, assessed at the one-year mark. Graduation is NOT a full discharge. Clients remain in the system for ongoing monitoring, scheduled 6- and 12-month follow-ups post-graduation and may re-activate navigation services without completing a full intake as symptoms and needs evolve

Assesses change over time by re-administering baseline measures to evaluate quantitative outcomes, inform program effectiveness, and support evaluation and funding efforts.