Innovative community nurse navigator program aims to keep patients healthy and out of the hospital.
At Longmont United Hospital, we care about each of our patients. But we also hope we don’t see you again too soon. Unfortunately, research shows about 20 percent of Medicare patients return to the hospital within 30 days of release. A follow-up program at Longmont United Hospital, led by community nurse navigators Renita Henson, RN, is designed to reduce the number of rapid returns by making sure patients get the help they need after leaving the hospital, so they can stay home and out of the hospital.
“Our job is to work with people to reduce their chances of going back to the hospital for the same issue,” Henson says. This means that the pair individualizes 30-day post-discharge care plans, based on patient needs. This may include a series of phone calls, home visits, help scheduling follow-up appointments, medication consultations, and navigating other post-discharge care. In addition to education and support, Henson says one of the most important things they do is help patients identify the specific thing that will motivate them to participate in their own care.
For example, a physician might tell a congestive heart failure patient to weigh herself every day. “I can tell her how to weigh herself,” at the same time every day, “and why,” Roth says. But that patient has to find her own motivator to do the weigh-in. Maybe it’s to remain living independently, to travel, or to be healthy enough to play grandkids.
“We do whatever it takes to help people get the care they need and to help activate them to be in charge of their own health,” Henson says.
The hospital also has a program, called EMMI, that makes an automated follow-up call to all recently discharged patients. The interactive system asks a series of questions and, if a patient has any concern, it triggers a red flag for Henson or Roth to make a personal follow-up call. The call helps identify patients with early warning signs who have not contacted a provider yet.
Focus on follow-up
Another one of Roth’s essential tasks is providing additional services to patients with primary care physicians in the Centura Health system. She calls each patient to schedule follow-up appointments, reviews medications, assess their needs, and helps connect them with community resources, which may include a referral to a social worker, chaplain, or chronic pain management group. Henson does the same with all patients who have been discharged to a nursing home to make sure they are settles in and things are going well and, of course, to get them on a course to get back home.