Navigator reduces readmissions, inappropriate ED visits

Pilot project paid for itself

When Lakewood Hospital in the Cleveland Clinic Health System brought on board a patient navigator to guide patients through the healthcare maze, the hospital saved $156,000 in just six months.

"The navigator’s interventions generated significant savings, covering the entire cost of the project in the first three months of the pilot program. In 2013, the navigator worked with 1,500 patients and only 3.16% were readmitted," says Sarah Fay, MBA, director of operations for The Center for Health Affairs, which worked with Lakewood Hospital and Accenture on a pilot program. Lakewood Hospital Foundation provided nearly 85% of the navigator’s salary during the pilot phase, with the Harold P. Freeman Patient Navigation Institute providing a grant for the balance, according to Mary McLaughlin Davis, DNP, MSN, ACNS-BC, CCM, director of case management for the hospital.

"The pilot was so successful that the hospital continued the program for another year with renewed funding from Lakewood Hospital Foundation and now in the third year, fully funds it," McLaughlin Davis says.

The pilot focused on reducing Medicare 30-day readmissions and reducing the number of self-pay patients who visit the emergency department for non-emergent care.

Patients in the pilot program who worked with the navigator experienced a 30-day readmission rate that was 4% lower than other patients, which saved the hospital a minimum of $29,702, according to Fay. Self-pay patients had 5% fewer revisits to the emergency department for a savings of $127,102.

"These patients were misusing resources because they didn’t understand where they should go for care. The navigator educated them that instead of going to the emergency department, they should go to an urgent care center for treatment when their doctor’s office is closed," she says.

Before the project began, a team from The Center for Health Affairs and Lakewood Hospital did an assessment within the hospital emergency department to determine where patients were falling through the cracks and what services a navigator should provide, Davis says.

"Our biggest challenge was trying to determine how to measure success. We are one of the smaller community hospitals and we don’t have an identifiable large high-risk group. We knew intuitively and experientially that many patients who came into the emergency department would come back again and again. The one common thread was that they didn’t have a primary care provider," Davis says.

Getting patients connected to a primary care provider was challenging because many of the patients didn’t have insurance and they didn’t understand the importance of having a primary care provider, she says. In some cases, patients’ primary care providers had retired and they had not established a relationship with another physician, Davis says.

The problem was compounded by the limited number of community physicians for self-pay patients and Medicaid beneficiaries. Often, lack of transportation to the physician office was a barrier, Fay adds.

The pilot’s goals were to reduce the number of 30-day readmissions and self-pay visits in a 30-day period by identifying barriers to care for the hospital’s population and developing strategies to eliminate them.

"We wanted to look at how a patient navigator would impact the patient experience and the bottom line for the hospital. The pilot proved that the benefits of having a navigator far outweigh the costs," she says.

The team hired Jessica Roberts to work as a full-time lay navigator. Roberts is stationed in the emergency department and reports to the case management department. "Her hours are based on the needs of the department. We looked at the highest volume, coupled with the follow-up appointment times and decided to focus in that time frame," Fay says.

Roberts works with patients who are admitted through the emergency department and patients who are not admitted but who do not have a primary care physician. She estimates that she sees about 95% of her patients in person. "Sometimes I receive referrals from the emergency department or surgery to work with patients who are not admitted but who need assistance," she says.

She sees some patients only once but works with many of them over time.

"I’ve been working with some patients since the beginning and have developed a relationship with them. If they experience problems with transportation or are confused about how to navigate the healthcare system, they contact me for help," Roberts says.

Roberts starts her day reviewing a list of all patients who were admitted, then goes on interdisciplinary rounds on units that have admitted patients overnight. "All the case managers know me and bring patients who might need more assistance to my attention," she says.

When patients are admitted, Roberts focuses on those who were admitted without a primary care physician. She meets the patients during rounds, then visits them later to discuss their discharge and help facilitate follow-up appointments. During the conversations, she often identifies barriers to care such as lack of childcare or inability to pay for medication and helps connect them with community resources.

"Many of the self-pay patients who are not admitted come in with non-emergent issues. Many do not have a primary care physician or they don’t understand how to utilize the healthcare system," Fay says.

Roberts helps self-pay patients find a medical home at a federally qualified health center or another low-cost clinic and facilitates a follow-up appointment. She helps them sign up for medication assistance, transportation assistance, and other community resources. She helps schedule orthopedic follow-up appointments for patients in the emergency department.

"I call patients the day before their appointments to remind them and make sure they have transportation," Robert says. She follows up to make sure they went to the appointment and to find out if they need any other assistance. She asks a series of general questions and, if the patient has questions or concerns, she can refer them to a member of the care team for follow up.

Roberts collaborates with the case managers and social workers on the unit and relieves them of duties that don’t need a license, such as scheduling transportation and setting up medication assistance. "The case managers and social workers feel less overloaded and are able to work at the top of their license with Jessica to support them," Fay says.

In the first year of the program, Roberts secured more than 1,000 follow-up appointments before discharge. The majority of those patients did not have a primary care practitioner.

"The greatest success of this program is giving our patients the ability to manage their own healthcare. And the hospital has been able to reallocate resources and caregivers to focus on other important aspects of patient care," Davis says.