Innovator Extra: Care-Traffic Controllers are Making Population Health Possible in Virginia

March 24, 2015
The advanced patient-centered medical homes (PCMH) at Bon Secours Medical Group (BSMG), a multispecialty organization that includes more than 600 Richmond, Va.-area physicians, is done on the backs of its mighty army of nurse navigators. Two of them explain their jobs to HCI in this Innovator Extra Q&A.

The advanced patient-centered medical homes (PCMH) at Bon Secours Medical Group (BSMG), a multispecialty organization that includes more than 600 Richmond, Va.-area physicians, is done on the backs of its mighty army of nurse navigators.

The medical group, which placed third in the Healthcare Informatics Innovator Awards Program for advanced value-based PCMHs and population health management, relies on the navigators—both embedded and administrative—to fill in the gaps of preventative care for both individual patients and an individual practitioner’s population. Robert Fortini, R.N. calls them the “care-traffic controllers,” Like air-traffic controllers are directing traffic to safely get planes in and out of an airport, “care-traffic controllers” are directing data and care services to treat patients who at risk for multiple chronic diseases.

Healthcare Informatics’ Senior Editor Gabriel Perna talked to two navigators, Angel Daniels, R.N. the clinical manager of the PCMH team at Bon Secours and Joyce Rusincovitch, R.N. a nurse navigator for an internal medicine and primary care physician practice, to better understand their role, how they utilize health IT systems, and the relationships formed between navigators and doctors. Below are excerpts from that interview.

What are your roles at Bon Secours?

Angel Daniels, R.N.: My role with the medical group, I oversee the work flows of the nurse navigators at primary care and specialty practices throughout the organization.

Joyce Rusincovitch, R.N.: I am a nurse navigator for West End Internal Medicine. There are a lot of hats we wear as nurse navigators but our focus is in population health management. In doing that, one of our main roles is to ensure when patients get out of hospital, we’re reaching out to them within 48 hours to ensure continuity of care, proper understanding of their discharge instructions, and the goal is to arrange their follow-up appointments in our office as well as any specialty offices. The overall goal is to keep them out of the hospital from being readmitted, to keep them back on track.

Another primary roll is we perform Medicare wellness visits in our office. It’s a free Medicare benefit and an avenue to keep our patients healthy and make sure they’re getting their immunization, mammograms and all of their routine health studies. It also gives us an opportunity to meet with patients, make sure they have advance medical directives. If they don’t we can facilitate those discussions.

Why are nurse navigators and in particular someone who is a nurse, the right people to provide this in the weeds, value-based, population health management?

JR: There are many moving parts in a healthcare system. To have the skilled eyes of a registered nurse, when we look at a chart for someone who is coming out of the hospital, it’s like playing Monday morning quarterback. If there is something that doesn’t get completed or needs more attention, we have the critical-thinking skills to look at and review a chart and see what’s going on. Physicians are seeing patients, so we’re providing that to physicians and the patients, to make sure they’re going in the right direction.

AD: I’d add the benefit of a nurse is having the clinical background and understanding of these conditions we’re dealing with every day with our patients. We’re used to being educators and looking at the patient as a whole from a wide range of things that could be barriers to their care. Nurse navigators, they’re an extension of that. They’re able to educate and figure out those barriers, which would be social issues, mental health issues, and a wide range of things that could be greatly involved with the management of their care.

How do you work with doctors, specialists?

JR: In my practice, I’m one of two embedded navigators. The plus side of being embedded is that we have that face-to-face, trust relationship with our physicians, so if we need to escalate concerns quickly, they are available to us. As far as specialists go, in the same turn, we use electronic medical charting, we do a lot of our communicating to physicians—ours as well as the specialists—through the electronic chart. If we need a more timely response, we pick up the phone and there are navigators in specialty offices as well.

The patients develop trust in us. They see our presence in the office. We’re an extension of the physician and they trust the physician. They see us and are empowered to utilize us as their go-to person to get to the physician.

What have some of the cultural struggles and challenges?

AD: When we started embedding navigators in our practices over four years ago, in the beginning, [the providers] did not know what to do with the [navigators] in their practice. They learned about building the trusting relationship, understanding [the navigators’] role and in time, most practices were requesting the navigators. They started to become dependent on the nurse navigators.

When a patient is transitioning out of the hospital, we have to explain to providers that within one week of discharge, that we need to schedule an appointment with them. Working with the provider to identify those wellness visits and proactive ways to manage care…those are some of things we have to had to work with.

Do they get it?

JR: They do. Part of Angel’s job is putting the right fit for a personality in with the right group. Not every nurse is going to be able to work in each practice. That’s where [Angel and other administrators] are very skilled in a management sense.  Once the physicians have gotten their navigators and that relationship built, they will understand. I had one of my physicians knock on my door today and tell me they had a patient that needed a Medicare Wellness visit while she was there. They get the gravity of utilizing time and tapping into our services.

Nurse navigators are utilizing what kinds of health IT systems?

JR: It starts with messages. We have something called MyChart where if patients choose to enroll, we can communicate with them. It allows them a different form of communication for just benign questions. It’s not for emergencies, but if they need a refill of a medication or have a question about instructions. A lot of those get routed to the nurses, not the navigators but the nurses that are working with the physicians directly. If they in turn, find it’s something that I’ve been working on, they will route it to us.  It’s another way to communicate with them.

We are also able to communicate with each other. We have specialists that are able to tag us on if they know we are involved. We can also help update the care teams to ensure the physicians and navigators that are touching patient are included. By doing that, we will all get notified if the patient ends up in hospital. It allows for earlier intervention, so we can reach out to the inpatient physician staff or case managers to help direct some of the care.

AD: With the electronic system we use…we’re able to track and coordinate care, look at test results, or what happened with the patient when they were in the hospital or ER. It allows us to capture data. We have a nurse navigator tool that we use which helps us identify high-risk patients or gaps in care. It gives us a lot of benefits.

JR: I had a patient that just got out of the hospital. She had some end-stage illnesses. Her appointment was scheduled to follow up with us. Before she could even get to the follow up, she was back in the hospital. I noticed because I got a notification and had been planning to see if she was coming in for her appointment. As soon as I saw that, I was able to contact the senior services emergency department and other care team members to help direct her care. What had helped was to get her a palliative consult; her family and her health providers are reviewing if she will go into hospice or what her plan is. That’s where it’s at now but all that happened a lot of faster because the real-time vision of being able to see things in the computer and being alerted into it.

What are some of the lessons you’ve learned that you’d like to share with others? And how can others emulate your efforts?

AD: For me personally, starting as a navigator and transitioning into the role of a clinical manager, the lessons I have learned in population management is the gratification of following a patient for more than a day or two from the inpatient side. Looking at the patient as a whole makes a huge difference in how we coordinate care and get them actively involved in management of care.

JR: Every day, I’m inspired by my patients and what they teach me, and having the ability to spend the time to get more involved with their care, to help with the population management and see how active they want to be in the management of their healthcare. Most patients want to be involved. It is going through it from a holistic approach. For me, I wasn’t sure what nurse navigation was when I started…it’s been the best change I’ve ever undergone. I learn something every day I come to work.  

Attending HIMSS15? Meet the minds behind Bon Secours PCMH initiative and other award winning teams at the Innovator Awards Ceremony. Register here.

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