Posts Tagged ‘nurse navigator’

Severity Index Drives Patients’ Touch Points with Nurse Navigators

August 12th, 2014 by Patricia Donovan

Beyond telephonic outreach, assessment and education, nurse navigators in Bon Secours Health System Advanced Medical Home also manage a case load for face-to-face patient work, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Here, he describes the process of assigning patients to nurse navigators.

Based on our learning experiences with the Geisinger system, it becomes difficult for an RN to handle more than about 150 patients, depending upon the complexity of the patient.

We also give back-line access, and the RNs all have beepers as well. They have the license to give that beeper number to the more complex patients—the frequent flyers who are going to need more attention. Or they can give that access to our colleagues on the managed care side who might be engaged in managing patients with a severe illness. To our case management team in the hospital, it just allows for more bandwidth and clearer communication across the spectrum of care delivery.

How does a patient get into a case load? It is by the physician’s decision. For example, Mr. Smith has seven different major active problems. He is on 18 different medications, he is 87 years old and he has a touch of Alzheimers. That individual needs hand-holding, so that would be the first way to give the patient case management. We also take referrals from the hospital and from our managed care colleagues. We are also using some predictive modeling tools provided to us by insurers to identify patients who need closer following.

How frequently a patient is touched, brought in for face-to-face care or called on the phone depends on the severity index. We use a tool my colleague designed that will calculate a relative readmission risk index based on several sets of criteria: number of medications, length of stay in the hospital, the acuity level of the patient in the hospital and whether or not they are in intensive care unit (ICU) initially, etc. How frequently they are touched depends on how high up the severity index they are.

Excerpted from: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination

3 Nurse Navigator Tools to Enhance Care Management

January 29th, 2014 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.