Digital Health Implementation Among Older Adults: Health Technology Navigators’ Perspectives

ABSTRACT

Objectives: Despite the rise in health technology, a persistent digital divide affects underserved groups, including low-income, uninsured or underinsured, and limited English proficient (LEP) patients. This study highlights lessons learned from a unique stakeholder—health technology navigators—about factors affecting digital health use among older and linguistically diverse patients in one of the largest US safety-net health systems.

Study Design: We conducted in-depth interviews with Los Angeles County Department of Health Services (LAC DHS) navigators from June to December 2023. Discussions focused on their job role, identity, experiences supporting older patients (≥ 50 years) to register and use the patient portal, and linguistically diverse patients (primary language other than English or LEP) in this safety net.

Methods: We used the Theoretical Domains Framework to create an interview guide. We interviewed 9 female and 2 male navigators across 9 LAC DHS clinics who were bilingual (English and Spanish). Interviews were transcribed and analyzed for major themes.

Results: Three primary themes emerged from the qualitative analysis: characteristics of a successful navigator, patients’ prior experiences with digital health, and barriers in the clinic.

Conclusions: Navigators highlighted older patients’ interest in learning to use digital tools and the need for support in digital health engagement. In describing their work with patients, navigators drew on their lived experiences with family and community to connect with these older patients in the Los Angeles safety-net health system. The lessons learned from these navigators can inform digital health engagement in other safety-net health settings so that they are more inclusive for older patients.

Am J Manag Care. 2025;31(5):In Press

Takeaway Points

Qualitative interviews with health technology navigators provide insights into portal enrollment for older, linguistically diverse patients in safety-net health systems.

• Health technology navigators are trained community health workers who help patients utilize digital tools such as patient portals.
• Navigators noted that barriers to portal enrollment for these patients included technical challenges, busy clinic workflows, and systemic inequities.
• This work adds to the literature by sharing perspectives from expert stakeholders—the navigators—on how navigation facilitates digital health implementation for older, linguistically diverse adults.
• These findings inform design of health technology navigation programs for more inclusive digital health access.

Despite the increase in utilization of digital tools in health care, there are widening inequities in access to digital technology, referred to as the digital divide, that particularly affect patients who are linguistically diverse and experience socioeconomic barriers.^1,2 Safety-net health systems, which consist of public hospitals, federally qualified health centers, and publicly funded community-based health care entities, deliver a significant level of health care services to these populations in addition to those who are low-income, uninsured, receiving Medicaid, from minority racial and ethnic groups, and limited English proficient (LEP) who are historically and contemporarily at risk for health disparities.^3-5

Studies have shown that safety-net patients are interested in engaging with digital health.^6,7 However, limited digital literacy, internet access, and confidence in using digital health technology are barriers to uptake, especially for those who are linguistically diverse or LEP.^6,7 Patient portals, which are secure websites linked to a patient’s electronic health record, have been shown to benefit linguistically diverse patients in the safety net by making it easier to refill medications, message the care team with questions, and attend appointments.⁸ But the literature has also shown that patients with LEP are less likely to register for an online patient portal compared with patients who speak English.⁹ A cross-sectional study in California reported that only 13% of Spanish-speaking and 17% of Korean- or Mandarin-speaking patients utilized patient portals for medication refills compared with 53% of patients whose primary language was English.¹⁰ One study in a San Francisco safety-net system found that existing telemedicine platforms were not optimized to support LEP patients and required added staff time and labor and work-arounds to make the platforms work for non-English speakers.¹¹ Initiatives such as bilingual patient portals have been introduced to address these disparities, yet challenges persist in ensuring these tools are accessible and user-friendly for LEP patients.³

There is also a gap in knowledge about how digital health looks for older adults in the safety net. Safety-net health systems typically care for a larger share of younger populations^5,12 because older patients tend to leave these systems once they are eligible for Medicare. However, older adults who are linguistically diverse may prefer to remain in safety-net health settings because of cultural congruence with health care staff, convenience, and familiarity with the setting.⁵ Safety-net health settings are projected to have more non–English-speaking older adults due to an increasingly diverse aging population experiencing socioeconomic disparities.^5,12 Furthermore, several studies have shown that middle-aged adults (≥ 50 years) prematurely age and develop chronic illnesses if they have experienced adverse social determinants of health.^13-15

Given that the literature has reported that older adults are also disproportionately affected by the digital divide, understanding their digital health access in safety-net settings is important.One study in a San Francisco safety-net hospital reported that middle-aged adults (aged 50-64 years) and older adults (≥ 65 years) had lower odds of expressing interest in a portal compared with adults aged 18 to 29 years.^11,16-18 A Kaiser Permanente diabetes registry analysis found that patients older than 70 years were less likely to enroll in the portal, but those who registered for the portal were more likely to log in and actively use the portal compared with patients younger than 40 years.¹⁹ It is important to better understand older adults’ interest in digital health services and pathways to effective engagement, as they stand to benefit from expanded health access.¹⁹

Health technology navigators are members of the health care team who are dedicated to supporting patients in using digital tools.^20,21 One systematic literature review in 2023 analyzed 48 behavioral health studies since 2010 on depression and anxiety, and it reported that health technology navigators fulfilled at least 1 of these 3 roles: (1) evaluating and recommending apps to patients, (2) setting up technology for patients and troubleshooting, and (3) analyzing digital health use and sustaining engagement.²⁰ Most studies reported that health technology navigators contacted patients once a week via text or in-app messaging and less commonly via phone calls or in person.²⁰ Because the COVID-19 pandemic accelerated the need for digital health access, there has been an expansion in health technology navigators beyond behavioral health services. In 2021, a blood pressure intervention reported utilizing health technology navigators who were available to chat with participants (adults older than 45 years) on the study app and assist with technology troubleshooting.²² Also in 2021, a primary care clinic in an academic medical center implemented a health technology navigator to assist patients with diabetes with signing up for a patient portal related to the disease.²³ In 2021, during the COVID-19 pandemic, Los Angeles County Department of Health Services (LAC DHS), the second-largest municipal safety-net health system in the US,²⁴ implemented a health technology navigator workforce.^24,25 Although LAC DHS may not be the first to utilize health technology navigators, it is the first safety-net health system, to our knowledge, to implement a health system–wide program for health technology navigation.²⁴ The health technology navigators of LAC DHS follow a community health worker model and focus on helping patients in the safety-net system enroll in and use the patient portal, download the health system mobile application, learn to use their smartphone, and set up video visits.^24,25

To learn about digital health engagement as it pertains to older, linguistically diverse patients in the safety net, we interviewed LAC DHS health technology navigators about their work experiences. The objectives of this qualitative study were to learn about (1) the navigators’ job role; (2) observations of how older, non–English-speaking patients in the safety net have interfaced with digital health; and (3) the digital health facilitators and barriers for this understudied population.

METHODS

Study Design and Setting

LAC DHS is an integral part of the health care safety net for Los Angeles County, the largest and most ethnically diverse county in the US.²⁶ LAC DHS serves more than 10 million patients who are publicly insured or uninsured.²⁷ More than 50% of the primary care patient population in LAC DHS is primarily non–English speaking (also referred to as linguistically diverse or LEP in this study).^26,28

Among the 119,730 patients enrolled in the portal at the time of our interviews, 65% of patients spoke English and 31% spoke Spanish (4% spoke another language); 39% were aged 36 to 55 years, 11% were aged 56 to 75 years, and 1% were older than 75 years.

Interview Guide

All interviews were conducted by the lead author (K.W.), who is a third-year medical student, from June to December 2023. Each question in our interview guide (eAppendix [available at ajmc.com]) corresponds to 1 or more domains in the Theoretical Domains Framework, which is a framework that assesses the behaviors and knowledge of individuals in an implemented program.²⁹ In our interview questions, we asked navigators to consider older adults as those 50 years and older, which is younger than the typical Medicare eligibility age of 65 years. This use of a broadened age group recognizes the literature showing that patients who have been exposed to trauma and negative social determinants tend to age faster.^5,13-15

Recruitment

We conducted 60-minute Zoom interviews with 11 LAC DHS navigators who were key stakeholders in digital health implementation. The audio recordings were transcribed. The lead author (K.W.) and senior investigator (A.C.) worked together to create a codebook to define recurring themes by reading through transcripts and referencing the interview guide and Theoretical Domains Framework. After the codebook was established, 2 coders (K.W. and A.M.H.) coded each of the 11 transcripts separately using Dedoose 9.0.17 (Sociocultural Research Consultants, LLC), which is a cloud application for analyzing qualitative and mixed-methods research data. For each transcript, the coders agreed on a common code or discussed with the senior investigator to settle questions. Our qualitative examination included thematic summary based on direct quotes from navigators, description of their experiences in the discussions, and the research team’s observations from interviews. Stakeholder interviews and qualitative summary were approved by the UCLA Institutional Review Board (IRB) with reliance on UCLA from the LAC DHS IRB.

RESULTS

Navigator Job Role and Workflow

Navigators approach patients in clinic waiting rooms or other clinic areas, such as the lobby or front desk, to ask whether they have enrolled in the patient portal.²⁴ If not, navigators define and describe the portal for the patient and offer to assist them with registering and downloading the portal application on their phones. The navigator can also call patients after they leave the clinic to continue assisting them with any troubleshooting. If a patient does not speak English or Spanish, the navigators use a telephone LAC DHS interpreter for communication.

Navigator Characteristics

We interviewed 9 female and 2 male navigators who worked across 9 of 12 of the LAC DHS sites. As described in prior work, the health technology navigators ranged in age from 20 to 30 years, were fluent in English and Spanish, and grew up in local communities served by LAC DHS.²⁴

Primary Themes and Pertinent Subthemes

Three primary themes emerged from the qualitative analysis: characteristics of a successful navigator, patients’ prior experiences with digital health, and barriers in the clinic. Pertinent subthemes for each theme are described below with representative quotes and navigator experiences embedded in the descriptive thematic narrative (Table).

Characteristics of a successful navigator. The study team observed specific features that likely make these navigators highly relatable, trustworthy, and engaging for their older safety-net patients. This included that the navigators were from the very communities that they served; displayed cultural humility, patience, and compassion; addressed health care questions outside the scope of the portal (outside their defined job); and performed innovative problem-solving.

Navigators perceived that being from the very communities that they serve was essential. They referenced their upbringing, family, or fluency in Spanish as being crucial for their job role. Many of them were raised in Los Angeles County and described experiences helping their own family members with technology. One said, “Spanish-speaking folks would gravitate toward me when they would hear me talk in Spanish to another patient.” Another navigator explained, “As a Spanish-speaking child, you learn what terms to use when speaking to an elder, and these are words of showing respect and remorse. So incorporating that terminology when speaking to these patients…they can see, ‘I can confide in them.’ ”

Navigators highlighted aspects of cultural humility and referenced their own memories of seeing their family members who felt isolated in English-speaking spaces. They strived to connect with patients regardless of their language or cultural background. One navigator explained, “A lot of patients are hesitant to [learn to use] digital devices because of that language barrier.… But if we’re speaking their language, we get that trust.”

Successful navigators also exhibited patience when teaching patients to use their smartphones and the patient portal. One navigator explained, “When some patients are stressed when they don’t get it right away, [it’s important to reassure] them.” Another shared, “I’ve had a lot of older patients say, ‘Thank you so much—not even my own kid takes time to explain things to me.’ ”

Navigators described assisting patients in their preferred language, and in turn, patients demonstrated trust in them by asking questions beyond the scope of the portal. Other topics they discussed with patients included insurance and locating immunization records. Navigators showed that they were compassionate when they allowed patients to confide in them about personal lives and challenges.

Navigators described innovative problem-solving to address barriers that older, non–English-speaking patients face when using the portal. When patients’ phones run out of storage for the patient portal app, navigators talked about saving the portal website as a bookmark icon on patients’ home screens. They also assisted patients with using autofill passwords and face ID and saving their passwords on a card in their wallets.

Patients’ prior experiences with the portal and digital tools. Health technology navigators related their perceptions on how older patients experienced digital health in this safety-net health system. In reference to this, they talked about perceived benefits of the portal for older patients, technical challenges in enrollment, stigma, interest, fear, and systemic/structural barriers.

Navigators described many benefits of using the portal for older, linguistically diverse patients. Before having access to the patient portal, older patients may have commuted to the clinic via bus to confirm the details of their next visit or to request a medication refill. And oftentimes to receive help on the phone, a navigator explains, “The wait time to talk to someone…[can be] about an hour, and it’s longer for Spanish-speaking patients.” Additionally, the patient portal can be used to check appointment locations, refill medications, and check laboratory results without calling or going to the clinic.

Navigators noted that older patients often encounter technical challenges enrolling in the patient portal. The 2 most common situations that navigators described were patients not knowing how to use their phone beyond making phone calls and not knowing whether they had an email address, which is required for portal registration. A unique challenge that navigators saw older non–English-speaking patients encounter was having their phones configured in English because their English-speaking family members or caretakers assist with managing their phones. Conversely, sometimes patients’ phones were configured in another language, such as Chinese, and this made it more difficult for navigators to teach patients how to use their smartphone.

Something that came up in interviews was the significant stigma surrounding older patients using digital tools. Navigators observed that health care staff could assume that these patients were not interested in using digital tools and not offer the service. Navigators described how it was especially frustrating when English-speaking family members, whom patients might rely on for language and technology assistance, turned down the portal for their parents and grandparents.

Navigators told us how older patients have interest in using the portal and digital tools. One said, “[Older patients] are really curious, and they really are interested in learning more about their health.… Having someone be able to explain to these things in their own language…is really vital.” Another navigator said, “[Older patients] are very intrigued to learn [about digital tools] because they’re learning [about] a new world. They have a phone, but they don’t know all the things that they can do with their phone.… We’re showing them a new world in the palm of their hands.” Navigators also noted that it was important to teach older patients in person, step-by-step how to use the patient portal. One navigator said, “People who are over 50…want to interact with a person….”

Navigators noticed that many older, non–English-speaking patients were fearful of the internet. In addition to being scared that their information or money could be stolen, these patients were noted to be distrustful of these systems built primarily in English, which have legal terms and conditions that are inaccessible.

From the navigators’ observations, systemic and structural barriers also make it harder for older, non–English-speaking individuals to utilize digital tools. Some older patients do not have home broadband access, and navigators help these patients locate community spaces, such as public libraries, where they can connect to Wi-Fi and log into the portal. For patients who do not own a phone, the navigators can refer them to get a free, government-sponsored cell phone. However, navigators noticed that these free government phones tend to freeze often, making it even harder for older patients with financial barriers to utilize the portal.

Barriers in the clinic. Some of the major frustrations that navigators discussed were the problems with Wi-Fi connectivity and clinic workflows that were not conducive to engaging patients on digital health.

Wi-Fi connectivity was a recurring barrier in the clinic that navigators mentioned slowed down the enrollment process, especially in clinics located in the basement level of some of these older clinical sites.

Navigators discussed that clinic workflow also could be a challenge for portal enrollment, especially due to the busy clinic schedule. For example, navigators noted that clinical staff are sometimes unable to allot enough time for navigators to enroll patients into the portal prior to calling the patient into the examination room. When patients check in with the clinic front desk, navigators described a pop-up question on patients’ charts asking about the patient’s interest in the portal. Navigators noted that to save time, staff may click “declined portal” without formally asking patients. A navigator shared, “If I go in a room and [their chart] says, ‘Yes, patient declined,’…a lot of patients [will] say, ‘I was never even offered [the portal].’” As a result, navigators approach all patients, including those with charts that say “declined portal,” and they noted that “many patients expressed interest in enrolling into the portal.”

DISCUSSION

This formative study underscores the importance of culturally tailored health technology navigation for engaging older, non–English-speaking adults. The navigators provided insights on the barriers to and facilitators of portal enrollment for older, linguistically diverse adults in the Los Angeles safety net. Technical challenges using phones, difficulty accessing emails, limited phone storage, and fear of the internet were reported barriers at the patient level. Stigma, financial challenges (such as not being able to afford smartphones or Wi-Fi), clinic workflow, and clinic Wi-Fi connectivity were noted challenges at the structural and system level. In 2024, a systematic literature review including 45 articles found that the most common barriers to digital health implementation for safety-net populations were workflow disruption, broadband quality/access, and patient preference for in-person care.³⁰ This was similar to our navigators’ opinions about clinic workflow, Wi-Fi challenges, and the importance of teaching older adults in person and step-by-step. Another study surveyed linguistically diverse adults in San Francisco and reported that for Spanish- and Chinese-speaking patients, smartphone access and language barriers commonly prevented patients from messaging their clinicians.³¹ Health technology navigators’ innovative problem-solving, patience, cultural humility, and bilingual language capabilities facilitated portal enrollment. One study in an academic safety-net system reported that clinics with culturally and linguistically concordant staff were most successful in engaging with patients to use telemedicine (video/phone visits).¹¹

These interviews supported that many older patients are interested in learning to use digital tools and the patient portal, although navigators observed that technology could intimidate older patients, especially if the proper support is not simultaneously offered. One 2022 study in a safety-net system found that patients reported hesitations about telemedicine but also experienced high satisfaction once they utilized it.³² This is in-line with our navigators’ observations that older patients, once enrolled in the portal, returned to tell navigators how satisfied they were with the portal despite initially feeling intimidated.

Limitations and Strengths

Study limitations included the small sample size of navigators as well as limited generalizability to safety-net health systems beyond Los Angeles County. However, each navigator has worked closely with hundreds of patients and discussed patterns they saw across many patient interactions. The insightful experiences of these navigators, who are part of the first health technology navigation program in a diverse safety-net setting, are a major strength of this formative study. Building upon these findings, future research can more fully explore digital health implementation from the patient’s perspective.

CONCLUSIONS

Interviews with these expert stakeholders—the navigators—demonstrated that older, non–English-speaking patients in the LAC DHS safety-net system are interested in digital health but experience technical challenges with systemic barriers across language and social determinants of health. Health technology navigators can be an important starting point for facilitating portal enrollment within this demographic. These interviews highlight the strengths of successful navigators: patience, resourcefulness, and lived experiences that foster stronger connections with patients. The health technology navigators’ approach to outreach can also be implemented broadly: Engage all types of patients, and challenge assumptions about those who may be interested in digital health use. These findings are crucial for informing future health technology navigation efforts at safety-net hospitals on how to be designed mindfully for older, non–English-speaking patients.

Author Affiliations: University of Rochester School of Medicine and Dentistry (KW), Rochester, NY; Department of Family Medicine (AMH) and Division of General Internal Medicine and Health Services Research (AC), David Geffen School of Medicine, UCLA, Los Angeles, CA; Los Angeles County Department of Health Services (VP, AA), Los Angeles, CA.

Source of Funding: Ms Wang received support from the Medical Student Training in Aging Research Program, the Gleitsman Foundation, and the National Institute on Aging (T35AG026736). Dr Hernandez was supported by the Health Resources and Services Administration Institutional National Research Service Award at UCLA, grant T32HP19001. Dr Casillas received support from a career development award from the National Institute on Minority Health and Health Disparities (K23MD16943-01).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KW, VP, AA, AC); acquisition of data (KW); analysis and interpretation of data (KW, AMH, AC); drafting of the manuscript (KW, AMH, AC); critical revision of the manuscript for important intellectual content (KW, AMH, AA, AC); statistical analysis (KW); provision of patients or study materials (VP, AA, AC); obtaining funding (AA, AC); administrative, technical, or logistic support (VP, AA, AC); and supervision (AC).

Address Correspondence to: Katarina Wang, BS, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642. Email: katarina_wang@urmc.rochester.edu.

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