HeartBeats Episode 12: Nurse Navigator: Navigating the Patient Experience

Host:

Hello, and welcome to heartbeats. I'm Cathy Murtagh-Schaffer, and I'm your host for this episode of heartbeats. This podcast is brought to you by Shipley Cardiothoracic Center, an educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program, Lee Health and matters affecting your health. Today, we have Heidi Shoriak, System Director for Community Care Outreach for Innovatus Care Solutions and Mikaela Smith, Nurse Navigator and Structural Heart Coordinator for Shipley Cardiothoracic Center, to talk about the Nurse Navigator program from Innovatus Health and Shipley Cardiothoracic. Welcome everyone and thank you so much for taking time from your busy schedule to discuss these state of the art programs, Heidi, perhaps we can start with you, what exactly is Innovatus Health and how do you Innovatus come to the decision to invest in community nurse navigators?

Heidi:

Well, thank you Cathy, very much for having me. So Innovatus Health is our clinically integrated network. We're here to support many activities of our organization, and one of those is to provide nurse navigation for several of the programs that Lee Health has embarked upon. The reason that we're utilizing nurse navigation is because we know it's a very effective way to help patients.

Host:

What were some of the initial struggles in getting the program set up?

Speaker 2:

Well, the initial struggles really are about hiring the right nurses to join the team and the right social workers, and then developing workflows and processes. The program began a year ago specifically for our CMS bundle program, and since that time we've taken on some other programs and so we've grown quite rapidly. So probably the biggest challenge has been bringing people on and the right people and getting them trained.

Host:

I know as a system we're working very hard to prevent readmissions to the hospital and being readmitted to the hospital is expensive for both the patient and the hospital. How do you see nurse navigators influencing this?

Heidi:

So the role of the nurse navigator is really to help patients with navigating the very complex healthcare system. So nurse navigators help patients and families really coordinate their care, address barriers and roadblocks that they run into. So for example, when they're discharged from the hospital, many times, they have a lot of specialty providers, their primary care doctor, a lot of different follow-up appointments. They may have changes in their medications, they may have some social barriers that are kind of preventing them to get to a point of being able to manage. And so the nurse navigators will do an assessment. They'll work with those patients and families to really address all of those matters. We do provide disease education, we make sure patients understand their medications and that they you know, have been able to obtain them. Transportation we address to make sure they can get to their follow-up appointments. Really, we set goals with them to improve their health and wellbeing. Looking really at the whole body, mind and spirit, and it's really a partnership with the patient families to help them.

Host:

It sounds like you guys are addressing a lot of the social determinants of care, and I, I think there's a lot of research out there that shows that it's, that's very important in getting the right care to patients. Heidi, what type of experience or personalities were you looking for when you hired RN, nurse navigators and social workers for the program? And you mentioned it was a difficult recruitment process.

Heidi:

It is. So really we look for well seasoned nurses, those nurses that are very patient focused with a diversity of backgrounds and experiences. The same with our social workers, we really wanted to have well-rounded individuals and we have to meet patients where they are, so it's very important that we have a good background to address many needs, and also clinical knowledge, of course. So, because it's a role that requires supportive inflexible individuals, it changes constantly and so it, it does require a special person that's kind of willing to kind of roll with all those changes and support the patient where they are.

Host:

I know one of the unique features of your program is that you have somebody on 24 seven, is that correct?

Heidi:

We do, we have a nurse on call 24 seven, happy to support any calls from patients or providers, try to help support if a patient presents to our emergency department and they feel they can address the needs and send the patient back home, but they may need some follow-up the next day those providers or staff from the ED can call us and we'll be happy to follow up with those patients.

Host:

That's a great program. That's a great program.

Host:

How is this different though from home health nursing and how do the two programs intersect?

Heidi:

Yeah, that's a great question. So we are not a skilled home care service. This team of nurses is out to provide the education to address barriers, to help people navigate and solve problems versus skilled nursing through home health is really about hands-on care. So that is not what we provide ours is really to address things from a very holistic perspective. So, we will address, you know, needs from the, the hurdles that they may be experiencing. Like they're having difficulty getting to an appointment, they don't have funding for a medication. We may be working with their provider to see if there's any alternative. So we really just try to look at, the whole picture and support the patient. But we do collaborate quite closely if they have home health, or even if they're in a skilled nursing facility and we've received a referral on them, we will follow up to make sure they transition well from the facility back home, and that could include of course, working with the home care provider that may be involved.

Host:

So, in other words, home health is more hands-on let me change your dressing, take your blood pressure, take your temperature, make sure that physically you're okay. And nurse navigators are there to make sure you've got your appointment, you can get to your appointment, you understand your medicines and etc. Is that okay?

Heidi:

Exactly, exactly. And I think the difference is, so for example, for a patient with high blood pressure, home health is in there monitoring that blood pressure. Our role will be to support to make sure the patient knows how to take their own blood pressure, knows how to keep track of their blood pressure, knows how to really address their concerns or, or needs with their physician when they want to talk with them about the problem. So, it's definitely a different aspect, and also, sometimes home health has finished with the patient and that's where our role can be also very key to make sure they've transitioned to independence. So, we do follow patients anywhere from 30 to 90 days and depending on the type of support they need that may include the nurse and or social worker, and then also we do have some behavioral health support on our team. We have a licensed mental health counselor and a licensed social worker that can provide counseling to address behavioral health needs. Then we also have another team that we work with that provides chronic disease education. So a lot of education and workshops that we'll try to connect patients to.

Host:

I know that, um, in my experience that families are often key to a patient's overall experience. And I recently read a wonderful paper on the cultural meanings of death and dying. And while I understand you, you guys, aren't working as palliative care or hospice providers, the paper presented a wonderful kaleidoscope of how families of different cultures perceive and deal with illness. And it was a great reminder that the way I, as a white female deal with illness doesn't necessarily mean that's how someone of Korean, African-American, Indian or Hispanic descent may deal with it. How are we training our nurse navigators to engage in our wonderful culturally diverse community?

Heidi:

Well wedo encourage ongoing cultural education and we learn pearls of wisdom working with different ethnicities. And we really share that among our team members. Our team is comprised of a very diverse group of nurses and social workers, different cultures, ages, face, and, additionally, we can reach out to the Lee health, diversity office to get additional support. Lastly, we do work pretty closely with both churches and our community organizations to help us kind of support different cultures and needs as well.

Host:

How are you dealing with the language barrier?

Heidi:

So, I'm fortunate that I do have some bilingual staff members, but we do utilize an interpreter service. It is a phone service. So if we go into a home or we're speaking with someone on the phone, we can use that service, and that includes all, all languages. It's part of the health system.

Mikaela:

Can I expand on that? So we have, we've created all the different education documents that match up with the procedure the patient's had and we have someone in our office who has developed spanish and portuguese versions of those documents as well. So, we share our education with Heidi's team and then they're able to use that to reinforce the education.

Host:

And that's a great note on collaboration between the two teams.

Host:

Mikaela, Shipley's Nurse Navigator program is dedicated to caring for cardiac and lung surgery, patients through their initial consult until they're discharged after their post-op visit. This must be a really exciting time for you and your two nurse navigator colleagues, and it's a wonderful opportunity to propel the already great quality of Shipley's heart and lung program even further. I think our listeners would be interested to learn what experience you bring to the nurse navigator position and how you feel your new role is going to benefit the patients you see?

Mikaela:

So, I've spent my entire nursing career taking care of the cardiac patient. So after graduation, I spent about four years on a cardiac unit building my foundation, learning all the ropes. And from there, I went to the cardiac cath lab, so another phase of cardiac care, and from there, I became experienced enough to go to the open-heart operating room. So I pretty much feel like I've mastered all phases of care for the cardiac patient. So with the nurse navigator program, the patients will benefit from a much more comprehensive communication between myself and the other two navigators, Morgan and Jessica, and the patients and families in which they will have access to one of us at all times for questions, concerns, education, anything that, that comes up for them. So our hope is that they will feel better equipped for their experience and that we will be able to manage their expectations. So that's a huge, that's a big deal, managing expectations. Yeah. So our goal is to be a source of knowledge and comfort, because we recognize this is a very challenging time for these patients and their families.

Host:

I want to go back to the family question. We know that families are probably the most vulnerable to anxiety, which can lead to disaster thinking while they're waiting during surgery. What interactions do you foresee the nurse navigator having with families during this time and how do you think this will help?

Mikaela:

So the operating room actually has a tech system, in which they'll receive most of their communication and updates from, but, we'll be following along wherever the patient is, pre-op, intra-op post-op, and we'll make contact with them before and after surgery. We will make sure that they know we're available to update them throughout the interoperative course if they have any concerns. And I think this will help alleviate some of that anxiety because we understand that the waiting period during surgery is very stressful.

Host:

It is one of the biggest areas of concern that crops up as a problem every day is a patient's understanding of how to take their medicines once they get home Mikaela, would you go first and describe how your interaction with the patient and the use of meds to beds is designed to help eliminate this confusion?

Mikaela:

Sure. So, the most important thing that we want is a safe discharge for our patients and meds to beds is designed to help patients eliminate confusion about their medications, whether, they are new medications or something being continued after they're discharged from the hospital. So the meds to beds program is designed to provide personal medication review and consultation with nursing staff and the pharmacy staff. The medications are hand delivered to the patient's bedside before they're discharged, and you know, typically they might stop at the pharmacy downstairs or they'd have to send a family member out to pick them up, but this way they can leave the hospital with the medications in hand. So the bedside delivery provides an opportunity for pharmacy and nursing staff to answer their questions and ensure they understand how to take their medications correctly. So, we think this service is pretty critical for patients with complex conditions requiring multiple medications that come with very confusing instructions.

Host:

Yeah. I think Lee pharmacy developing this meds to beds program has been absolutely critical in helping with our readmissions and patients understanding of how they take their medications. And I know we are trying very hard to encourage patients to take advantage of that program.

Mikaela:

Right, and one thing that patients might want to know is if they can resume refills through their established pharmacy and they can.

Host:

Yeah, this is a one-time shot. This is a one-time, prescription fill here at Lee, just so that we can get them out to their home without them having to make an extra stop or sending somebody out. As you said.

Host:

Heidi, would you like to follow up Mikaela's answer and describe how Innovatus nurse navigators are also helping with medication education and how this prevents readmissions?

Heidi:

Absolutely. So our nurses support patients by making home visits. They also support them with telephone follow-up and we always walk through their medications with them. And often we do find some issues when they're at home, where perhaps they have a duplicate medication or they did not, were unable to pick up a medication. So we really want to support a follow through to make sure a, that they have the appropriate medicines and, also that they know how to take the medications. And then if there are issues related to that, then we work with their providers to see what we can do to address the issues and their pharmacists as well. Because we, we to, uh, agree, absolutely that is a critical piece of success is that they have their medicines and they're able to take them.

Host:

And I, think we want to all encourage patients to ask questions when they're not sure. I know a lot of folks go home from the hospital and they've been prescribed new medications or medications that are actually the same as they have in their medicine cabinet only, it's a different brand name or generic name and that just lends itself to tremendous confusion or it's a different dose and they don't realize it. So, I think what you guys are talking about is an absolutely critical piece to keeping patients safe.

Host:

And then this brings up the whole issue of patient education and how best to provide that service. I know that for Shipley, we begin when the patient is seen in the office, but Mikaela, I'm sure you would agree, there's only so much you can accomplish in a single visit. How do you see the nurse navigator playing a role in education during the patient's hospital stay?

Mikaela:

Our nursa navigators will be rounding daily on the patients. The bulk of our time will be spent reinforcing education that was previously given, answering new questions, you know, as much as we can educate them during consultation, there's just a whole world of things that they don't even realize are about to happen or are happening. So ,when we go up there and visit the patient and their families, we spend all of our time answering the questions, reviewing procedures, reviewing test results, answering all the questions that they think of when they leave and they go home and 10 things pop into their head, or as soon as they get in the car, it's like, oh, I should have asked that when I was there. So, from the initial consultation, through the end of their post-op visit, we serve as a contact for them. Any time of the day, any issue, any question they might have, we want to make sure they have answers to their questions and concerns, and the impact will be that they feel their needs are being met and they have a reliable and trustworthy advocate at all times,

Host:

Heidi, I'm sure your group is attentive to education, as well as you've said, what other areas do they focus on once the patient has been discharged?

Heidi:

So, as Mikaela said, one of the things we've worked together on is that our team knows those, pieces, components of education that have been provided during the hospital stay and post-op course, and then we'll reinforce those as well. But additionally, we educate on a variety of things because we're addressing the holistic person. So in addition to perhaps the cardiothoracic component, there may be some other things that we will support them through, whether it be diabetes or high blood pressure, other, other medical areas that will provide education. We also educate them on community resources, and then we do have conversations about advanced directive. So really any, any piece of, kind of the continuum of care that a patient might need support or education on, we're happy to connect those dots for them. The other thing we really work a lot with patients is to ensure that they get to those follow-up appointments. So we know it's critically important that they are seen right after discharge from a hospital setting. And we know that makes a huge difference to prevent a readmission. So, that can be a hurdle for patients, we will help advocate to make sure they get those appointments, and support that effort because that's critical as well. So, in terms of education, we educate them about the importance of that because sometimes patients think, oh, I just got home from the hospital, I don't feel well, I really don't feel like, can I just put that appointment off?

Host:

I just saw the doctor the other day.

Heidi:

Exactly, and so we really talked to them about, we want to keep you healthy at home, and this is a critical piece, and so we, we try to really connect all those dots.

Host:

Well, this has been a wonderful discussion, and this is what makes Lee Health and Shipley Cardiothoracic stand out as a top hospital and top cardiothoracic program in the nation by delivering patients the right care at the right time. Do either of you have anything else you would like to add?

Heidi:

Just that it's really our privilege to support patients and that we are here to help. And so if you get a call from the nurse navigator, please understand we are here to support you and we're working closely with your providers to make your outcomes successful.

Mikaela:

I agree with Heidi. Yeah. We want the best for our patients. We want to make it a very pleasant experience as much as possible, even how challenging it is.

Host:

Thank you so much for being here today. I'm so excited about this new patient centric program that Innovatus and Shipley is beginning. Our patients are going to benefit greatly from this next time we meet. I'm sure you'll have some wonderful patient stories to share. And I look forward to hearing them. I'm Cathy Murtagh-Schaffer and this has been heartbeats Shipley Cardiothoracic Centers podcast, dedicated to bringing research innovation and education to our patients and the community.