Show Me the Way

patient navigators in cardiac care

By Camille Torres

If you’ve just been discharged from the hospital, the last place you want to end up is back in the hospital. For newly diagnosed heart patients, though, this is easier said than done. In 2014, one in four Medicare patients hospitalized with heart failure was readmitted within 30 days of discharge. The same was true for nearly one in five Medicare patients hospitalized with heart attack. Reasons for readmission varied, but many could be traced back to patients’ lack of understanding or incapability to follow discharge instructions.

But thanks to some recent changes to health policy, there’s a growing number of patient navigators. These professionals provide education, serve as a liaison with the hospital staff and provide emotional support for patients and their families — all with the end goal to improve patient health and reduce hospital readmissions.

Moving Toward ‘Value-Based’ Health Care

The Affordable Care Act has led to a shift from volume-based hospital reimbursement to value-based. More weight is being placed on quality of care and on achieving better outcomes per dollar spent. To incentivize this, the Centers for Medicare and Medicaid Services (CMS) increased penalties for hospitals with excessive 30-day readmission rates for heart attack and heart failure (essentially, less government reimbursement for hospitals with high 30-day readmission rates).

To improve care for cardiac patients and to help hospitals drive down readmission rates, the American College of Cardiology (ACC), in conjunction with AstraZeneca, launched the Patient Navigator Program at select hospitals.

“It’s a team-based approach to support heart attack and heart failure patients, helping them to avoid a quick return to the hospital while making a seamless transition from hospital to home,” says Marian Uy, manager of the Heart Failure and Structural Heart Programs at WakeMed Health & Hospitals, which was among the first hospitals chosen to participate in the program. “It also serves as a test for innovative, patient-centered solutions to address issues that impact patient health and hospital readmissions.”

Although patient navigator programs have existed in various capacities for
decades, the ACC’s program helped propel their growth. They have continued to expand in part because of their success in improving patient outcomes, but also because they improve medical care overall.

“These programs strive to develop processes, systems and structures that facilitate delivery of care based on highest evidence, and monitor quality over time,” says Nancy Albert, Ph.D., CCNS, CCRN, chair of the American College of Cardiology Patient Navigator Program Work Group.

Navigator Backgrounds

The navigator role exists at many hospitals, but the exact titles and roles vary depending on specialties and semantics. Some programs have patient navigators, while others have nurse navigators and/or clinical nurse navigators. Despite the variance, they all aim to improve patients’ care through collaboration.

Most navigators are RNs or BSNs, but some are social workers, pharmacists or nurse practitioners. Additional training and certifications differ among — and even within — hospitals, depending on needs. While one organization may serve more elderly patients, another may care for a larger number of non-English-speaking patients.

“Navigators who understand community resources and are trained in motivational interviewing, teach-back and discussions on end-of-life and advance directions will be better able to meet patient needs,” Albert says. “In addition, it is important to have a strong knowledgebase about the medical condition since patients often communicate worsening symptoms to navigators, and they need to be able to sort out emergencies from minor issues and know when to seek provider support.”

Knowledge Is Power

Patient education is a common thread among all navigator programs. When
patients and their families better understand their condition and treatment,
they’re more likely to thrive.

“Educating patients about their condition, providing instructions and home
follow-up after discharge and encouraging healthy lifestyle changes are key to helping our patients manage their cardiac conditions, stay independent and out of the hospital,” Uy says.

At Albany, New York-based St. Peter’s Health Partners, before patients have
elective heart surgery, their surgeons refer them to Gregory Watson, RN, PCCN, a cardiovascular nurse navigator. Watson teaches a pre-operation class, educating patients and their families on what to expect and do after surgery to promote healing. A dietician and an exercise physiologist also speak. Patients learn about sternal precaution and how to get in and out of a chair and bed.

“Every patient or family member who has taken the class says they feel less stressed and better informed,” Watson says. “Education is power. Most people aren’t medical, so it’s stressful taking care of someone after surgery. But after the classes, they are better able to recognize problems and know when to call to reduce readmissions.”

At Cleveland Clinic Heart and Vascular Institute, ICU navigators meet
with families on the day of surgery to let them know what to expect. Last year, they taught 13,000 people, sharing information ranging from the process of ICU to what the patient will look like after surgery.

“It’s about an hour-long presentation. It keeps the families busy while patients are in surgery and gives them all the information they need. It also keeps the nurses from repeating information,” says Rosemarie Pierson, RN, BA, cardiovascular surgery unit (CVSU) nurse coordinator at Cleveland Clinic.

Pierson transitioned from a bedside nursing role into a navigator position in 1997 to serve as a liaison between patient’s families and nurses. Now, she oversees the ICU’s team of four navigators, who are required to have at least a decade of ICU bedside nursing experience each.

The navigators continue to serve the patients and families after surgery. “For post-op open-heart patients, number one is education,” Pierson says. “It’s about giving them a good patient experience.”

In the hospital’s outpatient catheterization laboratory and electrophysiology area, Megan Roland, RN, serves as the clinical coordinator — the department’s version of a patient navigator. Her experience as an RN and cardiac step-down nurse enables her to discuss procedures in-depth, answer any questions and explain elements patients and families might have missed.

Roland also keeps patients and their families updated on procedures and wait times. “The constant communication with the families puts them at ease and makes them feel less anxious about everything,” Roland says.

At WakeMed, heart attack and heart failure patients receive education and support from a team that includes physicians, advanced practice providers, nurses and pharmacists, as well as a dietitian, physical therapist, respiratory therapist, spiritual care chaplain and a cardiac rehab program.

Patients learn about their disease, the prescribed medical therapy, the importance of a heart-healthy diet, lifestyle modification and the importance of medical follow-up and participation in a certified cardiac rehab program. If patients are at high risk for rehospitalization, they participate in WakeMed’s Heart Failure Program, which offers open access to critical care-trained nurses.

Once patients are ready for discharge, many navigator programs provide discharge classes. Nurses teach patients and their families what to expect when they go home, what warning signs to look for and when to call a medical professional.

The Emotional Connection

In addition to education, navigators provide emotional support, connect patients to resources and collaborate with other departments and services.

“Open-heart surgery creates a lot of anxiety and lifestyle changes. Therefore, communicating with the patient, family and staff builds trust to enhance nurse-patient relationships. Clinical navigators assist in addressing anxiety and concerns by actively listening and problem-solving,” says Sandra Zampino, RN, clinical navigator for Cleveland Clinic Heart and Vascular Institute’s step-down unit.

When Ernest Williams II—a member of Mended Hearts’ Cleveland chapter—was 15, he was diagnosed with Long QT Syndrome. During his stay at Cleveland Clinic, patient navigators visited him to make sure he was comfortable and to answer any questions he or his family had.

“It was easier to talk to a navigator than the doctor. Sometimes the doctor’s terminology might be hard to understand, especially if you’re worried or scared like I was. It’s good to have someone there to talk to you on the same level,” Williams says.  “While I was there, they also supported me by pushing me to stay on my medications when I left and not to miss any scans or appointments.”

What stood out to Williams, though, was the navigators’ understanding of his emotional condition and the balance they struck between giving him space and attention. Angry about the lifestyle changes that would inevitably accompany his condition, he pushed people away. “They gave me a chance if I wanted to have someone there. I didn’t want to be bothered by anybody. I had the feelings of ‘Why me?’ and was thinking it wasn’t fair,” Williams says. “They realized that and that they could be in the way. They understood where I was. They were always there just to check on me, and if there was something I wanted to talk to them about, they were there.”

Navigators’ support often also includes taking patients to procedures and connecting them with other caregivers. For example, if a patient at Cleveland Clinic’s cath lab has to have an emergency procedure, Roland continues to help the family and introduces them to the hospital’s ICU navigators. When a cardiovascular patient at St. Peter’s has testing or a procedure, Watson explains the procedure and takes the patient for testing, so she has a familiar face to travel the hospital with. He also transfers patients from ICU to the step-down unit.

Ongoing Assistance

Once patients are discharged, navigators oftentimes make or arrange follow-up phone calls over the next few months to ensure patients are taking their medication correctly and are attending follow-up appointments. If a navigator detects a problem, he’ll have the appropriate person follow-up and will arrange a visiting nurse if necessary. As a result, navigators catch issues while they’re minor, resulting in fewer readmissions.

At WakeMed, Heart Failure Program nurses call heart attack patients weekly for five weeks, and they follow heart failure patients even longer. If the patient has a problem, the nurses collaborate with the patients’ cardiologists and primary care providers. “This added support facilitates early interventions, thereby avoiding emergency room visits or hospitalization if possible,” Uy says.

In less than three years, WakeMed’s program has seen positive results. Only 3.48% of heart attack patients are return within 30 days, down from 6% at beginning of program. For heart failure, the 30-day readmission rate is 14% and has been as low as 10%, down from 20%.

Connecting with a Navigator

If you would like a navigator’s assistance, start by asking your cardiologist or hospital. Some hospitals’ navigator programs automatically serve all patients within a department. However, other programs require a doctor or nurse to assign a navigator, or one automatically visits a patient after a week of hospitalization. Other care centers do not have programs in place at all.

Regardless of whether a hospital has a navigator program, a patient or his family can request support for post-hospital care. Albert says, “Not all hospitals use the term ‘patient navigator,’ so if that terminology is used, a person may be told that there is no program when, in fact, all acute-care hospitals have some programs in place to ensure patients are connected to the services they need, even if it is not an integrated, team-based, collaborative transition care program.”

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