By Melinda Young


A program that used nurse navigators with heart failure patients cut its 30-day readmission rate in half and provided more thorough follow-up care in transitioning patients home.

  • The program also was used for sepsis patients, with the sepsis navigator connecting patients with community resources after discharge.
  • One basic idea was to help patients meet with their primary care providers before the following weekend after they were discharged from the hospital.
  • Nurse navigators worked with pharmacies to ensure patients received their medications after discharge.

By using nurse navigators, a hospital cut in half its 30-day readmission rate for heart failure patients.

“Readmissions for heart failure patients were an issue at our local community hospital, and actually nationwide,” says Karen Weeks, DNP, RN, CCRN-K, instructor at James Madison University in Harrisonburg, VA. Weeks worked as a heart failure nurse navigator for the pilot study.

Follow-up care can make a big difference in transitioning patients to their homes and keeping them healthy and out of the hospital. For a pilot study, nurse navigators targeted both heart failure and sepsis patients, she adds. Investigators found when the program started in January 2019, the readmission rate was 24.05%. In February 2019, the readmission rate dropped to 20%. In March, it was 19.75%, and in April, the readmission rate had dropped to 11.11%.

“It cut the readmission rate in more than half,” Weeks says. “I presented the findings to a senior leadership resource team, showing them the results of having a navigator and what costs were avoided. In October 2019, they created two full-time navigator roles. The cost avoided from readmissions [and Centers for Medicare & Medicaid Services penalties] paid for both nurse navigator salaries, and that’s how we justified it to the facility.”

Initially, nurse navigators targeted both heart failure patients and sepsis patients, but the person hired for the sepsis portion left the job. Then, the COVID-19 pandemic hit, and the sepsis navigator has not been replaced, Weeks says.

One reason the nurse navigator helps reduce readmission rates is because follow-up is important to keeping newly discharged patients healthy. “Follow-up is key, particularly in this area, which is more rural and providers are not available on the weekend,” Weeks says. “When I called on Fridays, especially in the morning, patients were gaining weight and were more short of breath. Getting them to call their physician about their weight gain and having them get into a physician office before the weekend, so they would not have to go to the emergency department (ED), was their only resource.”

The nurse navigator helps patients get into the doctor’s office before the weekend and makes sure patients receive an extra diuretic or whatever else they need to reduce their symptoms before the weekend. “Once they have a weight gain and are symptomatic, they were encouraged to call their provider before noon, and the provider could then see the patient before the weekend,” Weeks adds.

Navigators help fill the gap between when patients might be discharged with a home health order and the 72 hours or so when home health can visit the patient.

“There’s always this window when a patient is discharged that they start to gain weight or go back to old habits of salt intake and drinking a lot of fluids, and they come back to the hospital in heart failure and are readmitted,” Weeks explains. “We’re trying to catch them earlier to see and minimize their coming back to the ED.”

The navigator program included patients filling out a discharge ticket in which they noted who would be taking them home and how they would cook, clean, wash laundry, and whether they had necessary tools like a walker and shower chair, she says. Patients also explain how they will travel to their provider appointments, and show they know how to take their medication correctly.

“Heart failure patients often get confused on what medication they should take, so the discharge navigator goes into detail with them over multiple visits to help them understand what to take,” Weeks says. “The navigator collaborates with pharmacy to make sure patients can afford their medications.”

The navigator ensures patients have functional scales at home. Nurse navigators do not order medication, so this role does not have to be filled by nurse practitioners, she notes.

“The heart failure navigator is a nurse with solid expertise in cardiac care, and she does what I did for this research project,” Weeks says. “The sepsis navigator talks with patients about ways to prevent urinary tract infections, getting their flu shots, good handwashing, and those kinds of things.”

The sepsis navigator played an important role in connecting patients with community resources at or after discharge. For example, one sepsis patient had pneumonia and was a veteran. He told the navigator he could not afford the antibiotic prescribed for him to take at home post-discharge. He was going to wait to fill the prescription at a veterans hospital that was in another state — 90 minutes from his home, Weeks recalls.

“The navigator had to call the pharmacy and make sure he had medication before he left,” she says. “Then, the navigator followed up to make sure he was doing OK and would get his pneumococcal vaccine, flu vaccine, and was taking his antibiotics and probiotics.” The navigator collaborated with the pharmacy to find the man appropriate, equivalent, and affordable medication.

Patients with serious illnesses like sepsis and heart failure often are overwhelmed with their illness and need additional support and education.

“Navigators make sure they understand their medication,” Weeks says. “It mimics the breast cancer navigator for breast cancer patients, but it’s for heart failure and sepsis patients.”

Nurse navigators also spend more time with patients in education than do hospital case managers, she says. “It’s about coming into the patient’s room and diving down deep into what the patient requires. A lot of times, I would sit with patients for an average of 60 minutes.”

Spending that much time with patients builds trust and allows the navigator to learn things the patient would not share with hospital nurses and case managers.

For instance, when a navigator talked with a patient about her primary care provider visit after discharge, she learned the patient did not like her doctor. “I said, ‘Why don’t you find somebody else? Where do you live?’” Weeks says. “We connected her with another provider, when before her only option was to come to the hospital because she didn’t realize she could find another doctor.”

In another case, a nurse navigator learned a heart failure patient lived by himself and had limited access to healthy foods. He ate mostly processed and microwave meals.

“We found a heart-healthy market on the internet with low-sodium options that all he had to do was heat up in the microwave,” Weeks says. “He was internet-savvy, and he ordered them online at the equivalent of Walmart prices, but the sodium was low.”

Helping patients solve these types of obstacles requires a thorough research and attention to detail, she adds.