The in-field patient nurse navigator is increasingly being utilized to enhance medical delivery across the world. The innovative approach is growing rapidly as a model to discourse the complicated and often disjointed state of well-being, education, and social service provision. Currently, the in-field patient nurse navigator remains an integral part of acute congestive heart failure. It has also expanded through the medical care continuum to mitigate social determinants of health, including education, financial background, social support that can prevent a person's capability to get timely care. Clara Maas hospital is clear still facing numerous readmission rates after discharge. Although the healthcare providers make follow-up calls weekly for 28 days, it still readmits patients. For instance, in 2018, the number of patients admitted due to chronic heart failure was 271 and 47 readmitted, which stood at 17.34 readmission rates. In 2019, 224 chronic heart failure patients were admitted, and 4 were readmitted, which stood at 19.64% readmission rates. Although the hospital is lower than the National Target, it should target the readmission rate below 5%. Although the in-field patient nurse navigator is a relatively new model, the studies demonstrate that its impacts have continued to grow over time.
Problem Statement
There has been massive attention regarding healthcare facilities due to massive spending on readmissions that could have been prevented. The leading cause of readmissions is the poor quality of medical care. According to the Center for Disease Control and Prevention, more than 5 million people in the United States have heart failure and its resulting deaths of approximately 60,000. Treating acute congestive heart failure is costly, costing the country more than $40 billion annually (Pautasso et al., 2018). These expenses include the fines levied by the Affordable Care Act due to 30-day readmissions and have triggered numerous healthcare firms to evaluate the acute congestive heart failure risk factors that influence financial implications. A variable that increases patient readmissions is inadequate commitment and self-efficacy. Offering patients with detailed discharge guidelines can keep heart failure clients out of healthcare facilities and is a binding strategy to stopping later readmissions to the organization. The main challenge is inadequate care provided in the healthcare industry as the patient transition from discharge to home. When there is an interruption in transitions between hospitals and homes, the impacts are adverse as they link to the patient's superiority of care and self-care administration to prevent further hospital readmissions. This aspect prompted a need to develop a personalized care plan, discharge checklist, and risk stratification method.
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Background and Significance of the Study
Healthcare readmissions are expensive, widespread, and in numerous instances preventable. The roots of readmissions are due to numerous factors, and the degree of its effect differs significantly in each medical facility. Numerous studies have found that more than 40% of all hospital readmissions could have been prevented if in-field patient-nurse navigators had been available for all patients (Baileys et al., 2018). Acute congestive heart failure is the second foremost cause of hospitalization in the U.S. The condition is usually secondary to other heart issues such as heart attack, high blood pressure, or coronary artery disease. Approximately one million people are hospitalized annually as inpatients with the analysis of acute congestive heart failure, and about 300,000 patients are rehospitalized within 30 days of discharge with an approximated yearly charge of more than $3 billion for Medicare beneficiaries alone. This amount is considered as the 30-day readmission rate for acute congestive heart failure nationally is about 30% and greater in other facilities (Pratt-Chapman et al., 2017). In this case, the ordinary of readmissions for acute congestive heart failure is about 23%.
Due to these issues related to numerous hospital readmissions, implementing an in-field patient nurse navigator will assist patients in enhancing treatment adherence and increasing medical outcomes. Patients and healthcare providers will realize improved client satisfaction, reduced care inpatients, and enhanced medical outcomes. Other healthcare facilities such as Mercy Hope Hospital and many more have implemented the program and working effectively. The study will also offer healthcare information on how to guide patients, families on personalized and reliable heart failure information. There will also be aware of how to maximally utilize services and resources to enhance patients` quality of life to reduce overall mortality from acute congestive heart failure. The study will ensure that the model is patient-centered and sustainable service delivery interventions that will eliminate barriers to care throughout the healthcare continuum. It will also offer awareness on how to detect and diagnose the condition because the resources will be integrated into the medical system.
Literature Review
An electronic search was only limited to English language and peer-reviewed journals with corresponding abstracts and performed on numerous databases such as Medline, Google Scholar, and CINAHL. The keywords utilized in the search method include nurse, patient, navigator, diagnosis, and readmission. Few articles met the inclusion criteria. The chosen articles' references were also evaluated for potentially relevant studies. The initial search produced 900 potential articles. The author reviewed titles, abstracts, and articles. 890 articles were excluded because they were not within the 6-year range, not original studies did not highlight the transition of care, and lack evidence-based nursing care guidelines.
With an increasing understanding of offering personalized care in hospitals, many hospitals are applying in-field patient-nurse navigators to classify admitted acute congestive heart failure patients to enhance transition and healthcare results. Di Palo et al. (2017) utilized a navigator team consisting of a nurse and clinical pharmacist to deliver evidence-based intermediations. The authors theorized that the outcomes would enhance the documentation of heart failure patients and decrease 30-day all-cause readmission rates. Patients were monitored from admission to discharge and were give at least one recommendation that mainly revolves around social requirements and medical literacy. Di Palo et al. (2017) found that the 30-day all-cause readmission rate was about 18% for the Patient Navigator Methodology and 30% for the healthcare facility. Associated to the healthcare facility, there was a figuratively substantial rise in awareness and follow-ups. For patients who got particular Navigator Team interventions of medical understanding and proper traditions, the readmission percentages were 10.3% and 6.1%, respectively. According to Di Palo et al. (2017), to achieve these results, there should clear responsibilities of each navigator team from the time of admission to the healthcare facility until the period of discharge. They recommend that medical providers identify heart failure as a vital diagnosis during hospitalization through everyday team conversation, confirm heart failure diagnosis by organizational documentation in medical records, and utilize teach-back techniques to ensure patient recalls.
With emerging worldwide payment methods, healthcare organizations must comprehend the long-term effects of care transition methods. Balaban et al. (2017) determine the impact of care transition technique by utilizing nurse navigator on medical service usage among high-risk danger net patients within 180 days. The authors argued that the 30-day readmission percentage has the standard eminence extent to assess hospital-to-home transitional care. However, the authors decided to evaluate the impacts of patient navigators on readmission rates through six successive periods, each containing 30-day measures. The 180-day perception determines if an implemented technique could achieve maximum readmission reduction and benefit patients over a long time. Through randomized controlled trials, the authors enroll patient navigators and allow them to postulate the figure of patients to admit every day to uphold the everyday number of 20-35 patients per full-time patient navigator. The study results were that a 180-day usage evaluation offers an essential balance to 30-day readmission procedures. While the 30-day quota evaluates the impact of the care transition approach, the 180-day measure pursues to compute the effect of the care program. The authors found that older patients demonstrated a constant reduction in hospital-based usage over 180 days. Additionally, the findings proved that patient-nurse navigation programs assist patients to get required post-discharge care, avoiding unnecessary admissions and enable medical providers to make accurate healthcare decisions.
There is also other numerous literature that supports the study. Bachoo et al. (2016) hired a Nurse Navigator to study heart readmission rates within 30 days. Navigation techniques comprise interventions with a navigator team enrolled in telemonitoring services and heart failure education from the multidisciplinary teams. The authors performed a retrospective chart evaluating consecutive clients who enrolled in the healthcare facility between 2014 and 2018. They developed a flag for healthcare facility discharges before and after October 2016 to separate the information before and after the program's timeframe. Bachoo et al. (2016) evaluation the link between the intervention and technique between and 30-day readmissions through a Chi-square test and did multivariable logistic regression to evaluate the relationship while regulating other client determinants. The authors found that out of 1248 records with the program's timeframe, the patients’ elements remained the same, but the 30-day readmission percentage was considerably lesser for patients admitted during the intermediation. A rate of 3% decreased the rate of hospital readmission. Within this one healthcare facility experience, the authors concluded that launching a personalized heart failure discharge planning was related to a remarkable decrement in 30-day readmissions.
Staying healthy and preventing unnecessary hospital utilization is essential for both patients and healthcare providers. There is a growing interest among healthcare organizations whose readmissions rates are higher than 30 days because they receive heavy monetary funds from the Centers for Medicare and Medicaid Services and other insurance companies. Prieto-Centurion et al. (2019) argue that popular evidence-based methods to reduce preventable patient readmissions such as Care Transition Program, Better Outcomes by Optimizing Safe Transitions, and Project Re-Engineered Discharge. All these techniques utilize numerous strategies such as care coordination, well-structured follow-ups, healthcare reconciliations, and patient awareness, among others. Prieto-Centurion et al. (2019) proposed the Patient Navigator to Reduce Readmissions (PArTNER) as the best method for a healthcare organization. The authors diagnose patients with numerous conditions such as chronic obstructive pulmonary disease (COPD), pneumonia, sickle cell disease, heart failure, and myocardial infarction by utilizing the method. The program lasted for two months, and the authors utilize two groups: Navigator intervention vs. Normal care. The navigation team included community healthcare workers and peer coaches. The authors found that navigator intervention is the best approach to decrease readmission rates among patients.
Needs Assessment
There has been increasing awareness about the need for specialized attention for patients suffering from acute congestive heart failure in the current years. Additionally, the healthcare facility has been searching for the latest techniques to provide personalized care during the transition. The in-field patient-nurse navigators have been identified as the best technique that can be utilized to enhance the type of transitional care that patients get. Also, it has been proved to be the best way that can assist decrease readmission within the first 30 days of discharge (Villani et al., 2019). This plan has been developed to offer a roadmap on how the program can be utilized at the Clara Mass Medical Center, Belleville, New Jersey. Currently, the healthcare facility faces numerous 30-day readmission rates among patients with acute congestive heart failure. The trend is due to ineffective ways that are being utilized by the Transition Care Unit.
The Transition Care Unit comprises three full-time registered nurses. In many instances, some nurses are missing from work due to vacation or sick. Every morning, many patients are admitted in in-house diagnosis, and the transition will evaluate and monitor the assessment of the high risk. After the patients have been adequately monitored, the information is further accessed. The transitional care workers will visit patients in their wards to offer essential information about the resources and the social determinants of health (Poe, 2018). The awareness will revolve around treatments, living conditions, nutrition, among others. Since the interventions in use are not effective, a navigator program should be put in place to decrease the trend. The program stakeholders will be affected by the program, including Clara Maass Medical Center, Transition Care Unit, and nurses. The other stakeholders include patients, students, and tutors of the nearby nursing schools. These stakeholders will be taught about the program's advantages and how they can be implemented successfully within the healthcare facility.
Objectives
To implement an in-field patient nurse navigator program to avoid readmission rates in acute congestive heart failure patients within the first 30 days after discharge.
To decrease care costs for patients with acute congestive heart failure by 10% within six months.
Project Plan
The Gantt chart shows the design and implementation of the patient-nurse navigator program applicable for the company. It will run from 30th December 2020 to 21st November 2021. Fully integrating the program will take a short time (Wagner et al., 2016). Developing the program takes a long time because it involves preparing it and creating awareness to all stakeholders, which is vital in preventing opposition. Also, evaluation of the program will determine how workable it is before its complement implementation. The results will be evaluated regularly to make necessary changes.
Evaluation
When patients are admitted to the hospital, they expect excellent services that will make them recover quickly and return to their regular life. Also, the patient requires assurance that they will get better. In the latest intervention, the focus will be to enhance the quality of life by implementing the patient-nurse navigator. Two vital metrics will be evaluated to determine whether the intervention is successful or not. The first metric is the percentage of hospital readmission. Before integrating the program, it is essential to determine the hospital readmission rates within 30 days after discharge and compare them after implementing it. The second metric will be the cost of care. Transitional Care terms will determine the expenses of caring for patients before and after integrating the latest intervention. The cost of care will be approximately 2000 dollars. The percentage will be compared keenly and systematically to monitor the effect of the intervention. The initial implementation cost of a program like this is estimated to be 5000 dollars.
Impact on the Organization
The medical sector is a dynamic industry. It is characterized by variation in the ways patients are handled in healthcare facilities. Additionally, the introduction of the latest methods and technological transformations can be utilized to manage chronic diseases. The proposed intervention is meant to enhance the way patients get transitional care. If implemented, the organization will no doubt record numerous advantages if the patient-nurse navigator program is effective. The first advantage is that there be a massive reduction in the readmission rates within the healthcare facility. These benefits are essential because they will be of significance to both the patients and the organization. The second benefit is that there be a massive decrement in the costs of hospitalization. The program will improve the quality of care and lower the cost of healthcare within the facility. When the rates of readmissions are lowered, the time and resources are significantly reduced. High mortality rates and other adverse effects related to hospital readmission will be reduced when the patient-nurse navigator program is fully implemented.
References
Bachoo, M., & Tecson, K. (2019). The effect of nurse navigation program on 30-Day heart failure readmissions. Journal of Cardiac Failure , 25 (8), S133. https://doi.org/10.1016/j.cardfail.2019.07.382
Baileys, K., McMullen, L., Lubejko, B., Christensen, D., Haylock, P., Rose, T., Sellers, J., & Srdanovic, D. (2018). Nurse navigator core competencies: An update to reflect the evolution of the role. Clinical Journal of Oncology Nursing , 22 (3), 272-281. https://doi.org/10.1188/18.cjon.272-281
Balaban, R. B., Zhang, F., Vialle-Valentin, C. E., Galbraith, A. A., Burns, M. E., Larochelle, M. R., & Ross-Degnan, D. (2017). Impact of a patient navigator program on hospital-based and outpatient utilization over 180 days in a safety-net health system. Journal of General Internal Medicine , 32 (9), 981-989. https://doi.org/10.1007/s11606-017-4074-2
Di Palo, K. E., Patel, K., Assafin, M., & Piña, I. L. (2017). Implementation of a patient navigator program to reduce 30-day heart failure readmission rate. Progress in Cardiovascular Diseases , 60 (2), 259-266. https://doi.org/10.1016/j.pcad.2017.07.004
Pautasso, F. F., Zelmanowicz, A. D. M., Flores, C. D., & Caregnato, R. C. A. (2018). Role of the Nurse Navigator: integrative review. Revista gaucha de enfermagem , 39 . https://www.scielo.br/scielo.php?pid=S1983-14472018000100503&script=sci_arttext
Poe, J. L. (2018). Care Coordination: Using a Nurse Navigator in an Endoscopy Unit. https://encompass.eku.edu/dnpcapstones/33/
Pratt-Chapman, M., Burhansstipanov, L., & Shockney, L. D. (2017). Building a navigation program. Team-Based Oncology Care: The Pivotal Role of Oncology Navigation , 63-83. https://doi.org/10.1007/978-3-319-69038-4_4
Prieto-Centurion, V., Basu, S., Bracken, N., Calhoun, E., Dickens, C., DiDomenico, R. J., Gallardo, R., Gordeuk, V., Gutierrez-Kapheim, M., Hsu, L. L., Illendula, S., Joo, M., Kazmi, U., Mutso, A., Pickard, A. S., Pittendrigh, B., Sullivan, J. L., Williams, M., & Krishnan, J. A. (2019). Design of the patient navigator to reduce readmissions (Partner) study: A pragmatic clinical effectiveness trial. Contemporary Clinical Trials Communications , 15 , 100420. https://doi.org/10.1016/j.conctc.2019.100420
Villani, G. Q., Villani, A., Zanni, A., Sticozzi, C., Maceda, D. P., Rossi, L., Pisati, M. S., & Piepoli, M. F. (2019). Mobile health and implantable cardiac devices: Patients' expectations. European Journal of Preventive Cardiology , 26 (9), 920-927. https://doi.org/10.1177/2047487319830531
Wagner, M., Tiffe, T., Morbach, C., Gelbrich, G., Störk, S., & Heuschmann, P. U. (2016). Characteristics and course of heart failure stages A–B and determinants of progression – design and rationale of the STAAB cohort study. European Journal of Preventive Cardiology , 24 (5), 468-479. https://doi.org/10.1177/2047487316680693
