Seamless Care Navigation Guides Patients Through Treatment and Recovery
Patients managing a chronic condition and those transitioning home after a hospital stay can face many challenges, from understanding complex care instructions to accessing the medical, financial and social services they need throughout recovery. As part of the Adventist HealthCare systemwide care navigation program, Adventist HealthCare Rehabilitation employs a team of clinical and nonclinical healthcare professionals. This group helps patients navigate the system so they complete their rehabilitation plans as instructed to achieve the best possible outcomes.
“We have adopted an approach that combines care navigation throughout the entire healthcare system that, includes all our acute-care
hospitals, our rehabilitation hospital, our home health agency, and all 1,300 physicians in our clinical integrated network,” said Brent Reitz, MSPT, MBA, president of Post-Acute Services at Adventist HealthCare Rehabilitation. “The connection to the broader health system helps us make sure that people are moving seamlessly around the health system and access our continuum of services.”
The Importance of Care Navigation
Research has shown that helping patients navigate the healthcare system helps ensure that the continuum of care is unbroken.
Patient navigators, for instance, can schedule appointments with a patient’s many providers and ensure the patient has transportation to and from those appointments. The navigation team can translate complex instructions into a patient’s native language and educate the patient about the importance of following those instructions.
Navigators also serve a vital role for providers.
“Healthcare is complicated for anyone to get around, even for those of us in healthcare,” Brent said. “Our care navigation program helps patients receive the right care in the right place at the right time in their treatment journey by directing patients to the right provider in the appropriate care setting. Care navigators also work with physicians to make certain they’re kept informed. We help to make sure people are getting to the right level of care and that they’re fully informed when they transition between various services.”
The Adventist HealthCare navigation program spans three settings – our hospitals, outpatient settings and home health – and includes nurses, social workers and community health workers.
The outpatient care navigators follow patients as they leave our acute-care hospitals and progress to the next level of care, whether that involves home health, acute rehabilitation or a skilled-nursing facility.
A third care navigation team works with our physician practices to help stabilize patients and reduce the risk of rehospitalization.
“Instead of patients jumping from one service to another service where nobody knows them, we’re able to maintain a flow of information,” Brent said. “At times, patients see similar providers in different settings, our rehab hospital being one of them.”
Providing Access to Vital Recovery Services
Rehabilitation plays a vital role in care plans for patients managing chronic heart conditions, cancer, physical injuries and many other acute and chronic illnesses. Integrating our care navigation services with Adventist HealthCare Rehabilitation has allowed us to ensure patients get connected with the rehabilitation program that meets their needs.
“We are fortunate to have acute rehab within our organization,” said Kate Stradar, BSN, MBA, RN, associate vice president of care navigation at Adventist HealthCare. “It’s a powerful tool to help patients recover as fully and quickly as they possibly can.”
In addition to connecting patients with rehabilitation services, our navigation teams help patients understand their coverage and help them find financial services or charity care programs, if necessary.
“It’s not uncommon to see somebody with no insurance and no ability to get insurance who has had a stroke,” Kate said. “That person needs rehabilitation as much as the person with insurance.”
Accepting Help for Better Outcomes
The Agency for Healthcare Research and Quality found that patients who are involved in their healthcare plans and well-informed and engaged in their treatment have better outcomes. The care navigation team at Adventist HealthCare seeks to help patients take charge of their health by acting as their support and guide.
“We are taking care of people during a time that they're particularly vulnerable,” Kate said. “In most of our patient’s cases, they are out of their element and not feeling well. So, to have somebody who supports them, who is their helper, who is their navigator helps them through a tough time.”