Nurse Care Navigation
How Nurse Care Navigation Can Help Your Practice and Patients
The days and weeks after a hospital stay or emergency department visit are critical for patients, especially those at high risk for readmission.
Primary care practices participating in the Adventist HealthCare Physician Alliance can opt into the Nurse Care Navigation Program to help ensure optimal outcomes. In addition to improving the quality of care, nurse care navigation can reduce readmissions and health-related costs and result in shared savings. The program is free for participating practices.
What do nurse care navigators do?
Adventist HealthCare employs eight nurse care navigators who follow about 100 patients each a month. When a patient in a participating practice is discharged from the hospital or receives emergency department (ED) care, a nurse contacts them by phone to see how things are going. During the conversation, they also make sure the patient understands the following:
- Their discharge/after-visit instructions
- What their medications are for, and how to take them
- Red flags that could indicate a need for medical care
- When to follow up with their PCP or a specialist
In addition to assessing the patient’s health status, the nurses do a social determinants of health screening. Depending on the results and patient’s circumstances, the nurse care navigators may guide them to community resources, such as Meals on Wheels, financial assistance programs, home health providers, long-term care facilities and behavioral health providers.
How long do nurse care navigators follow patients?
Nurse care navigation follow-up varies depending on the patient’s needs. Patients who received care for a one-time event, such as an appendectomy or orthopedic injury, may just need two or three phone calls from the nurse care navigator. Patients with more complex medical conditions need longer follow-up with frequent phone calls for one to three months. The most common diagnoses in this patient group include uncontrolled diabetes, chronic obstructive pulmonary disease and congestive heart failure.
How do nurse care navigators collaborate with Primary Care Providers (PCPs) to ensure success?
Nurse care navigators work closely with PCPs and their staff to ensure good communication and coordination of care. This relationship looks different for every participating practice. Some nurse care navigators are “embedded” in certain physician practices, making in-person conversation easy. In some practices, these nurses see the patients during a primary care follow-up appointment. Weekly video conferencing calls, notes in the electronic medical record and meetings with providers, medical assistants and office managers also foster good care coordination. Each practice can decide what works best for them.
When they aren’t supporting patients after a hospital stay or ED visit, nurse care navigators often work behind the scenes to identify and follow up with patients within a primary care practice who need extra attention. For example, these patients may be behind on health screenings or overdue for annual check-ups.
What are the benefits of using nurse care navigation?
Nurse care navigators are an extension of the primary care provider’s practice, and many patients express gratitude for the additional support they provide. Over the years, the program has helped participating practices meet quality metrics, leading to increased shared savings.
