Emergency Department Nurse Navigation

Northwest Texas Hospital 491 Beds

◦ 385 Acute◦ 106 Behavioral

2014 ED Patients – 54,927

150 mile radius (Texas, Oklahoma, New Mexico, Colorado and Kansas)

Teaching Hospital (Internal Medicine, OB/GYN, and Pediatrics) 

2014 CMI – 2.08  2014 Medicare ALOS – 4.3

ED NURSE NAVIGATION Funded through one of the State’s Delivery System Incentive

payment programs

Target population are patients with Ambulatory Care Sensitive Conditions (ACSC) and have visited the ED >4 times in the past year◦ Angina◦ COPD◦ CHF◦ Diabetes◦ HTN◦ Seizures

Program Objectives: ◦ Track, follow up on and manage care for chronically ill patients who

utilize the ED for primary care◦ Improve access to care of patients◦ Establish primary care for patients without primary care providers◦ Schedule primary care appointments ◦ Address barriers to primary care utilization

 ED NAVIGATION

2.4 FTE’s◦ Lead Nurse Navigator ~ Full time◦ 3 part time positions = 24 hours per week◦ Coverage

0800-2000 M-F 0800-1700 Weekends

 All Navigators were ED Charge NursesAdvantages:

◦ Familiar with high utilizer patients◦ Established relationships with nurses and ED

physicians◦ Extensive knowledge base of appropriate levels of

care

ED NURSE NAVIGATION ORIENTATION

One week shadowing hospital Case Managers

One week shadowing hospital Social Workers

Tours◦ Primary Care Clinics◦ Behavioral Health Agencies◦ Substance Abuse Agencies◦ Homeless Shelters

In-Services◦ Home Health◦ Hospice◦ Skilled Nursing◦ LTAC◦ Rehab

Project Implementation – October 1, 2014

Identifying Target Population

◦ Identified by report showing patients with >4 visits◦ Compared the identified patients with the ACSC diagnosis◦ If matched, patient is contacted for agreement to enroll in

Navigator Program◦ Patients are flagged on First Net by initiating ED treatment

plan document

  Main Initial Assessment

◦ Verbal enrollment agreement from patient following explanation of the navigator role

◦ Living Situation◦ Chronic Conditions◦ Primary care & last appointment◦ Medications & Compliance◦ Payor Source◦ Barriers to primary care◦ Current resources

Patient Instructions 

◦ Navigator cell number is 806-398-WELL◦ Contact Navigator prior to coming to ED (unless life threatening)◦ Contact Navigator if have barriers to primary care visit◦ Contact Navigator regarding barriers obtaining medication

(transportation expense, etc)◦ Advise patients to expect follow up calls

   Navigator Follow Up

◦ Face to face visit with patients during ED visits◦ Telephonic visit with patients following after hour ED visits◦ Telephonic contact with patient prior to primary care

appointment for reminder and barrier identification◦ Preemptive calls based on individual patients utilization and

needs◦ Visit with patients during hospitalization and ensure PCP

appointment is made

NAVIGATOR PATIENTS 200 Enrolled patients – 10% (20) deceased

Contact◦ 18% Face to Face◦ 79% Telephonic

40% Male / 60% Female  16% did not have Primary Care Provider upon enrollment,

currently 5%  50% have history of behavioral health treatment   40% have history of substance abuse  73% have history of chronic pain complaints

24%

41%

19%

2%

14%

Navigation Patients Primary Financial Class

MEDICAID MEDICARE WYATT (City Indigent Program)INSURANCE SELF PAY

ED VISITS ADMISSIONS RE-ADMISSIONS

10/13-5/14 Before Navigation 311 90 20

10/14-5/15 After Navigation 193 28 4

25

75

125

175

225

275

325

OUTCOMES Top 25 Utilizers

What We Have Learned…..

Utilization of the ED for primary care is a generational learned behavior and hard to break 

The ED is more convenient and appealing◦ Decreased waiting time◦ No Payment◦ Entertainment of people watching and social interaction◦ Open 24/7

Many patients do not know where/how to establish a primary care provider

Patients are more likely to follow through with appointments immediately following an ED visit or hospital discharge because they do not feel well

  Systems/Resources are very complex to navigate and understand. Many

patients have attempted to self navigate in the past, but gave up.

ED Doctors and staff are recognized for actions that support the navigation project

DOCUMENTATION AND TOOLS

ED Track Blue Triangles indicate enrolled patients

Discharge Screen Identifies patients that come into the ED after hours to trigger follow up

ED Navigator Intervention Log Entries generate reports

Reports Menu

EXAMPLES OF SUCCESS STORIES

Mr. L is a 56 year old man who frequently visited the ER, 24 times in the past year to be exact. At the time the navigation program began, he had lost his Wyatt funding, was homeless, and was a heroin addict. He is a diabetic but had no glucometer and no way to fill his medications. He would come to the ER repeatedly for his chronic back pain so that he could obtain pain medications but would ignore his diabetic condition. He would end up admitted at the Pavilion because he was depressed and suicidal and literally had nowhere to go. The nurse navigation program provided this man with the opportunity to share his story and be able to receive the support and guidance he so desperately needed. The first step was convincing him to stop using heroin; this was actually accomplished during his next Pavilion admission. We were able to help him become enrolled in the Salvation Army recovery program and get his Wyatt funding renewed. Salvation Army provided him funding to attend the Pavilion outpatient program and he has faithfully attended this for several weeks. Our nurse navigation hotline has been beneficial to Mr. L—he calls us nearly every day! Many days it is to convince him that he does not need to come to the ER for a pain shot but other days it is just to give him moral support and encouragement. We have not managed to keep him out of the ER entirely, he still averages twice a month, but we have been able to reduce admissions. He has a working glucometer and adheres to his medications. We are still working to establish trust and rapport with him and working diligently to keep him with his primary care provider. He is now 124 days clean and has found a job. Our navigation services have certainly impacted this man and hopefully restored not only wellness, but also his dignity.

A young, poorly controlled diabetic patient comes to the ER often. She has had 7 visits in the past year, all requiring admission for diabetic issues. She is only 40 years old but appears much older. She does not have a glucometer and does not take her insulin. Time and time again, she is dismissed without funding and without a primary care physician and ends up in the ER acutely ill. As an ER nurse, I wondered why such a young woman could be so non-compliant. I would even educate her when I cared for her about the importance of checking her blood sugars and using her insulin. When I spoke with her in my new role as a nurse navigator, I learned that she had experienced a rough life. She was diagnosed as a diabetic at an early age but her mother was rarely home and her relatives provided little help to her so she learned to manage her condition on her own. She began using drugs and eventually ended up in jail for a year. Sadly, this time was the only time in her life that her diabetes was managed and she did not end up admitted. Before going to jail, she had Wyatt funding but did not go to appointments or follow up appropriately so she ended up losing her funding. She had reapplied but never taken in the required documents. I was able to call her frequently with updates and reminders and was finally able to get her funded with Wyatt again. She has attended her orientation and first appointment with her primary care and completed scheduled lab work. She is checking her blood sugars and adhering to insulin administration, hypertensive medications, and diet and she has not come in to the ER or had an admission in 4 months now. It is unfortunate our program did not exist 10 years ago for this patient since her disease progression has already caused irreversible complications for her but at least she has been given the opportunity to finally take some control over her conditions.

A 64 year old lady comes to the ED often, 23 times in a year actually. She comes in with vague symptoms, never requiring admissions. She always arrives by ambulance and always leaves by cab. She is a somewhat needy patient and staff considers her a frequent flyer, I was one of those staff members. Since nurse navigation started, she came in again and I saw her in a different role with a new set of eyes. What is her story? She is fully funded and faithfully goes to primary care. She admits she is not happy with her primary care and feels she is a burden when she calls. She lives with her son in a trailer and has home health that comes every week. It would seem this patient has all the resources she needs however a conversation brings out multiple red flags. She is lonely and comes to the ER because she is bored. She lets it slip that she really likes our sack lunches so food is an obvious motivator for visits. I learn she lives on $800 a month and pays for the trailer, the lot, utilities, and a car which she cannot even drive. Her son does not work and lives on this income. She receives $86 a month for food which her son also uses. She has the same bandage on her arm from a lab draw at the ER 5 days ago. I discuss Jan Werner with her so that she could change her primary care and have social needs met while also having access to daily meals and home visits and she is eager to explore this option. She ultimately did go for her Jan Werner intake and I learned she asked for food twice while she was at the hour long intake appointment. I am deeply saddened and moved. She has been at Jan Werner for nearly 9 months and is thriving. She has gained 10 lbs and gets her hair done every week. She participates in all activities and is enjoying getting to have friends. She has not had an ED visit in over 9 months. This navigation program has certainly made a difference to this sweet woman.

What’s Next?

190 Additional Patients October 2015 through October 2016