The PArTNER Model

PATient Navigator to rEduce Readmissions (PArTNER)

Download the PArTNER model guide PArTNER is a transitional care model for Minority-Serving Institutions (MSIs) that aims to increase support to patients with one of several chronic diseases, including COPD, and their caregivers at the hospital through their transition home.

The problem

Often, there are gaps in the discharge process when a patient is transitioning from the hospital to home.
The patient sometimes serves as the only bridge between the hospital and home, while they are still recovering. This puts patients at risk during the transition of care. It can also cause extra stress for the patient and their caregiver.

Transitions of care without the PArTNER model:

When patients have limited resources, the gap can be even bigger. 
This problem was felt by patients + caregivers at an Illinois Minority-Serving Institution (MSI). Researchers talked to patients and caregivers from a MSI in Illinois about their hospital experiences. They said they wanted more support while in the hospital and once they were back at home. They also said they felt anxious about taking care of themselves after leaving the hospital.

“When I was diagnosed with CHF and COPD, I didn’t get no good talking to, you know, this is what to do now, this is what you need to change and stuff. You know, they just tell us, diagnose us with stuff. I be getting to think I’m a guinea pig.”

Model design

With PArTNER, there are two added supports that strengthen the bridge between the hospital and home—the patient navigator and the peer coach.

Transitions of care with the PArTNER model:

The PArTNER model has multiple components.

The patient navigator visits the patient in the hospital at least once to assess for + address any health-related social needs like housing, transportation, food or utilities.
The patient navigator visits the patient at hospital discharge to go over discharge instructions and introduces them to their peer coach over the phone.
The patient navigator visits the patient at home 1-3 days after hospital discharge to review discharge instructions and provide support to address any health-related social needs.
The peer coach calls the patients 5 times over the next two months to review discharge instructions and provide support to address any health-related social needs.

For more detail download the one-page PArTNER guide.

Participant snapshot

The PArTNER model was initially tested with 1,029 patients hospitalized for heart failure, myocardial infarction, pneumonia, COPD or sickle cell disease at a MSI in Illinois.

On average, characteristics of the PArTNER patient population at a MSI:

  • 50 years of age
  • 82% of participants were black
  • 50% had a high school degree or less
  • 50% had annual household income less than $15,000
  • had 3 hospitalizations in the past year
  • 25% stated that the Emergency Department is their main place for medical care

Coming soon: Findings

Full findings from a pragmatic, clinical effectiveness trial testing the PArTNER model are expected to be available soon.

Staff + partners

The PArTNER team would like to thank the patient navigators and peer coaches for their devoted care and support of the PArTNER participants.

The PArTNER team would also like to thank:

  • The University of Illinois at Chicago PArTNER study staff
  • The PArTNER Steering Committee members
  • The PArTNER External Advisory Board members
  • The PArTNER Principal Investigators and Co-Investigators

For more information, contact the Population Health Sciences Program, University of Illinois at Chicago at