Navigators help patients manage their health

Interventions tailored to the individuals

Patients who participate in Hospital Sisters Health System Medical Group’s Nurse Navigator Program have shown significantly fewer emergency department visits and hospital visits as well as better control of their chronic conditions than patients who are not being followed by a nurse navigator.

“This program provides one-on-one support to patients at moderate to high risk to help them learn to manage their conditions and access the community resources they need to stay healthy at home and avoid hospitalization and emergency department visits,” says Jonna Herring, RN, executive director of quality and performance improvement for the Springfield, IL-based medical practice.

The program, based on a model developed by the Geisinger Health System in Pennsylvania, began in 2009 with a pilot in two medical practices with 11 physicians. The program had been expanded to nine medical group practices, and plans call for an additional 5 practices to come on board by July 1, 2013.

The program provides care coordination for at-risk patients with diabetes, chronic obstructive pulmonary disease, asthma, hyperlipidemia, coronary artery disease, hypertension, and heart failure. The nurse navigators and physicians search the patient database to determine which patients with chronic diseases would benefit from care coordination. “We have specific criteria based on clinical outcomes and measures,” Herring says. For instance, if a patient with diabetes does not have his or her hemoglobin A1c level under control, that is an immediate trigger for the nurse navigator program.

Patients who have multiple comorbidities, who are being discharged from the hospital, who make multiple visits to the emergency department, or who have other significant heath care needs are also eligible for the program. “Sometimes the providers feel that patients need someone to rally around them and help them understand their condition and they refer these patients to the navigators,” she says.

After patients are identified for the program, their physician talks to them about the services they will receive and how they will benefit. If patients agree to enroll, they meet with the nurse navigator.

The first meeting between the patient and the nurse navigators is up to an hour, depending on the level of concern the physician has. “The nurse navigator tailors the encounters to meet the specific needs of the patient. We know that when it comes to coordinating care for patients, there’s no ‘one-size-fits-all’ formula,” Herring says. For some patients, an initial meeting and follow-up phone calls are all that are needed. Some patients need a lot of extra help and the navigators meet with them at the physician office as often as two or three times a week in the beginning, then taper off. “Patients also know they can call the nurse navigators if they have questions or concerns,” she says.

The nurse navigators educate patients on their treatment plan and motivate them to follow it and take control of their health. “The navigators are the cheerleaders for their patients,” Herring says.

During every visit, the navigators assess their patients’ conditions and add information to the electronic medical record to keep physicians and nurses up to date on what is going on with their patients.

When patients are due for a recommended procedure or test, the nurse navigators contact the patients and make sure the appointment is scheduled. They review the results and alert the physician if there is a change in the patient’s condition.

The nurse navigators educate patients on how to manage their conditions and on signs and symptoms that indicate that they need to take action. For instance, with heart failure patients, the nurse navigators emphasize the importance of weighing every day and provide scales if needed. “We teach them what to do when they gain weight or their ankles swell and help them learn the triggers that indicate whether they should call the doctor or go to the emergency department.”

Nurse navigators have helped patients with such diverse needs as identifying affordable healthy foods, finding low-cost exercise programs, and signing up for pharmacy assistance programs as well as educating them about their diseases and treatment plans.

“The nurse navigators build a very strong relationship with their patients. If the patients are interested and willing to participate, the navigators become their new best friend,” she says.

The nurse navigators have a patient load of no more than 120 patients at a time, allowing them to spend as much time as necessary with patients who need it.

The physician practices are working to establish relationships and share information with community hospitals. The physicians and hospitals have been working together on a readmission and discharge program to ensure that patients have a follow-up appointment and are taking their medication as prescribed after a hospital discharge.

“The hospitals directly affiliated with us have the ability to share information on hospital admissions and emergency department visits. In addition to looking at patients who already are being treated at our practices, we are looking at those who haven’t been a patient here but need a medical home. We want to keep these patients from falling through the cracks and help prevent readmissions,” she says.