Navigating Rehabilitation’s Role in Patient Navigation


By Kristina Marie Kokorelias

When you or someone you love is faced with an illness or injury, navigating the maze of our healthcare system is enough to distract from the goal of simply getting better. Transitioning across healthcare settings, where patients are moving across care settings and providers, often take place from hospitals to inpatient rehabilitation facilities (1), outpatient centers, or even home (2-4). Experiencing this tumultuous trajectory can be jarring for patients and their family caregivers (5), leading to sub-optimal outcomes (e.g., increased hospital re-admissions, being discharged to long-term care instead of home when being home is preferred), and may go against patient values who may prefer to age at home (6-8). Incorporating rehabilitation services from the point of diagnosis throughout the care trajectory, and potential care transition settings, for many patient populations is needed to improve cognitive and functional outcomes (15-17).

Luis Melendez (Unsplash)

Rehabilitation care is uniquely situated within the healthcare system, given the focus on the return of function, health and wellbeing (15). Given how common transitions are during the course of someone’s illness or injury, strategies that improve care transitions from acute care hospitals to complex continuing care and rehabilitation are encouraged. This article will demonstrate the role rehabilitation experts have in advancing patient navigation to help improve the integration of rehabilitation earlier into the healthcare trajectory.

While individuals benefit from rehabilitation early in the course of their recovery (1), gaps often occur during transitions in care that result in persons not accessing timely rehabilitation services.

While individuals benefit from rehabilitation early in the course of their recovery (1), gaps often occur during transitions in care that result in persons not accessing timely rehabilitation services. The reasons for this include a lack of knowledge, limited access to services, or difficulty with program adherence (9,10) (e.g., due to transportation or scheduling barriers (11,12)). At the same time, the coronavirus disease (COVID-19) pandemic has increased the number of patients who will require specialized rehabilitation services (13). COVID-19 may exacerbate the challenges patients face when navigating the healthcare system, such as when transitioning from acute care settings to rehabilitation, as services may be withdrawn or unavailable for some patient groups (e.g., the shift to virtual care) (14,18). Strategies to improve access to rehabilitation care early in the care trajectory are therefore encouraged (19).

Calls have been made from the World Health Organization to strengthen the linkages between acute care and rehabilitation care, but the uptake of this concept is slow due to the lack of integration between different care settings (17). Therefore, novel models of care are needed to increase uptake of necessary rehabilitation; contributing to improved patient outcomes. Patient navigation is emerging as a patient-centered care strategy to reduce barriers to care, such as improving access to rehabilitation.

Patient navigation is emerging as a patient-centered care strategy to reduce barriers to care, such as improving access to rehabilitation.

Patient-centered care is defined as a model of care that considers patients’ unique experiences of illness and the active collaboration and shared care decision-making between patients and care providers (19). Patient navigation programs first emerged in Canada to reduce barriers to care and improve the integration of care in the context of cancer (20), but have since evolved to meet the needs of patients with a variety of health conditions, including diabetes, dementia, and cardiovascular disease (21). Patient navigators are designed to ensure equitable access to care and assist with timely access to and coordination of care services for patients transitioning between care settings (22-24). Patient navigators may be lay navigators (i.e., peers with lived experience) or professional navigators (i.e., trained professionals).

Multiple professions could serve as professional navigators with them most often being nurses, social workers, or counsellors (25,26) and the scope of practice varying. However, the patient navigators assisting with access to rehabilitation is scarcely mentioned in recent the literature, (26) except in a few studies focused solely on individuals with cancer (27) and stroke (28).

As members of multidisciplinary healthcare teams, rehabilitation clinicians (i.e., clinicians working in a rehabilitation setting such as physiotherapists) have a well-defined role in supporting the health and well-being of individuals with illness and disability across various settings of care. Similarly, rehabilitation clinicians have the expertise to manage the care of patients throughout various stages of illness and injury trajectories.  Scholars have argued that when the patient navigator role is incorporated into rehabilitation settings, professional navigators could improve the assessment and management of functional impairment and reintegration to meaningful occupations in individuals with injury or illness (27,29,30).

Filling whole system patient navigator roles with rehabilitation clinicians could expand the capability of patient navigation by providing the patient access to a healthcare provider with expertise in clinical assessments focused on rehabilitation and reintegration into the community (27). In comparison to lay navigators, rehabilitation clinicians would be able to provide clinical assessments to tailor care plans and service referrals to each patient’s and family member’s needs. Rehabilitation clinicians also have a unique focus on independence, participation, quality of life that other clinicians may not have, making them well-versed in caring for diverse patient populations within the specialty of rehabilitation medicine.

Incorporating more rehabilitation clinicians as patient navigators could result in numerous opportunities for clinical assessments that could assist with the goals of rehabilitation and may improve patient outcomes. Moreover, rehabilitation clinicians often already utilize the service navigation aspects of their roles (e.g., referral to other providers/services, help clients and families understand rationale for rehabilitation therapy) and therefore have the capacity and skills to contribute to patient navigation programs as they continue to be implemented across Canada. Rehabilitation clinicians are also well suited to perform other functions of patient navigation including assisting with patient goal setting (31), self management (26) as well as providing emotional support and education. Lastly, clinicians would also have an intimate knowing of the rehabilitation system accompanied by existing relationship with other care providers.

At the same time, non-clinical rehabilitation professions (i.e.., administrators and researchers) could have an important role supporting patient navigator programs to advocate for improvements to navigating health systems. Specifically, non-clinical rehabilitation professionals can assist with developing awareness of the patient navigator role among rehabilitation clinicians. Rehabilitation scientists can lead research to help define and evaluate the role of patient navigators in research. For instance, qualitative research could be conducted to identify the patient navigation health system needs of patients and their caregivers. Likewise, intervention and evaluation research is warranted on the effectiveness of different types of program models (i.e., lay vs professional navigators) and clinicians in navigator roles on outcomes of navigation in rehabilitation settings. Research should support the optimal scope of patient navigators across health and social care and community settings to promote health and well-being. Lessons learned from the design, implementation, and evaluation of the rehabilitation patient navigator role could have implications for future health systems policy development.

Edward Jenner (Pexels)

In addition to in-person healthcare, the COVID-19 pandemic has resulted in an increase in virtual care. Rehabilitation clinicians and researchers can lead the expansion of virtual patient navigation. Virtual patient navigation systems have been defined as a web or mobile application that provides reliable health information and timely access to services (32). Existing studies have shown the positive impact of virtual patient navigation for patients’ across the care trajectory, although not specific to the rehabilitation journey (33-35). Rehabilitation clinicians, with their experience caring for patients through virtual means, could help inform the development of a virtual patient navigator program. Rehabilitation researchers could help to evaluate the impact of a virtual rehabilitation patient navigator program.

Many patients requiring rehabilitation often have multi-dimensional (i.e., mixed physical, emotional and psychosocial) healthcare needs, necessitating transitions across different settings and providers of care.

Many patients requiring rehabilitation often have multi-dimensional (i.e., mixed physical, emotional and psychosocial) healthcare needs, necessitating transitions across different settings and providers of care. Unfortunately, Canada’s healthcare system is distinctively complex and the lack of coordination amongst providers can lead to navigational challenges that often results in individuals having poor outcomes following a care transition.

Patient navigation has emerged as a method to help with system coordination and access. However, patient navigation is slow to emerge in the context of rehabilitation. The concept of patient navigation has the potential to improve access to rehabilitation care and consequently, health outcomes (36-38). Consequently, rehabilitation clinicians and researchers should be encouraged to assist with the implementation of patient navigator programs within rehabilitation delivery systems. Rehabilitation patient navigators can help patients and family members adapt to new healthcare settings and dysfunctions in the rehabilitation systems and in the broader healthcare system. As high-quality care for individuals with illness or disability is often multi-faceted, patient navigation may not the ‘be-all-end-all’, but it may not be a bad place for rehabilitation to start.


Featured illustration by Sherry Ann for rehabINK.

To refer to this article, it can be cited as:

Kokorelias KM. Navigating Rehabilitations Role in Patient Navigation. rehabINK. 2021:11. Available from:


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