3 Nurse Navigator Tools to Enhance Care Management

Wednesday, January 29th, 2014
This post was written by Jessica Fornarotto

Where does the nurse navigator spend their day? Certainly on transitions of care. Bon Secours Health System nurse navigators use a trio of tools to identify patients’ obstacles to care and connect them to needed resources, explains Robert Fortini, vice president and chief clinical officer of Bon Secours Health System.

One tool that our nurse navigators use that’s built into our EMR is the hospital discharge registry from Laburnum Medical Center, one of our largest family practice sites with about nine physicians. This tool is used to identify which patients the navigators need to work with, and it’s where the navigators begin and end their day. This registry provides a list of all the patients who have been discharged from one of our hospitals in the last 24 hours, and each patient is listed by the physician. The navigators have to reach out to each of these patients and make telephonic touch within 24 to 48 hours of discharge. Medication reconciliation is extremely important at this time and can be very challenging. When a patient goes into a hospital, often their medications get scrambled, and they come out confused and taking the wrong prescriptions. Nurse navigators spend a lot of time on medication reconciliation at this point.

The Navigators also conduct ‘red flag’ rehearsals with this tool, so that the patient knows the signs and symptoms of a worsening condition and what to do for it. We also schedule the patient with a follow-up appointment, either with a specialist who managed the individual in the hospital or with their primary care physician. We try to do it as close to the time of discharge as possible, within five to seven days, or more frequently if the risk of readmission is higher.

Second, nurse navigators also use a documentation tool to help manage the care of heart failure patients. This tool allows the navigator to stage the degree of heart failure using a hyperlink called the ‘Yale tool.’ The Yale tool allows us to establish what stage of heart failure the patient is in: class one, two, three, or four. Then, a set of algorithms is launched based on these stages’ failure; we manage the patient according to those algorithms. For example, if a patient falls into a class four category, we might bring them in that same day, or the next day, for an appointment rather than wait five or seven days because they’re at more risk. We might also make daily phone calls or network in-home health, as well as make sure that the patient has scales for weight management and an assessment of heart failure status. All of those interventions will be driven by the patient’s class of heart failure.

The last tool we use is a workflow for ejection fractions. The patient’s ejection fraction will define specific interventions that the navigator will follow.

Excerpted from: Profiting from Population Health Management: Applying Analytics in Accountable Care.

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