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How Navigation Can Help in Decreasing Readmission Rates and ER Visits

By Tricia Strusowski MS, RN


January 19, 2017
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FACT #1:The last place that cancer patients and their family want to be is in the hospital. Hospital stays also increase the chances of hospital-acquired infections, which can result in a longer length of stay and complications.

FACT #2: Patients and family members do not feel well equipped upon discharge from the hospital, especially when it comes to how to handle procedures at home such as dressing changes, central lines, injections, and drains, just to name a few. Medications can also be very confusing, in particular when there have been changes—adding or removing medications, and/or dosage changes.

How can a nurse navigator help? Let’s start by reviewing the roles and responsibilities of the navigator, which often encompass the following:

  • Coordinate the care of the patient and family from pre-diagnosis through survivorship or end-of-life services, removing barriers across the continuum
  • Provide education and access to clinical trials, utilizing proper health literacy techniques
  • Improve patient outcomes through education, psychosocial support, and performance improvement monitoring
  • Collaborate and facilitate communication between patients, family members/ caregivers,
    and the healthcare team
  • Coordinate care across the continuum with the healthcare team
  • Provide cancer program and community resources, and follow-up
  • Participate in multidisciplinary clinics, tumor conferences, and cancer committee, functioning in the role of patient and family advocate

Given these responsibilities, how can nurse navigators help keep our patients out of the hospital?
First, we need to listen to our patients and their caregivers, and we need to share their story with the entire healthcare team. What are their specific concerns and educational needs? Keep in mind that these may have little or nothing to do with their diagnosis or plan of care. A comprehensive assessment of needs is essential for patients and caregivers to become empowered and successful during cancer treatment and to prevent avoidable admissions and ER visits.

Here are helpful tips for navigators to understand and meet these needs:

Patient and Caregiver Education

  • Discuss the preferred learning style of the patient and caregiver during the intake process
  • Create a disease-site-specific patient appointment checklist that includes information on why their appointments are important
  • Use decision-aid tools to empower the patient and caregiver with the appropriate questions to ask their providers and healthcare team
  • Proactively screen your patients for specific support service needs, e.g., dietitian, social worker, etc.
  • Provide safety tips for the home environment or have a home assessment completed
  • Use the same educational materials across the care continuum to decrease confusion for the patient and family
  • Teach patients/caregivers about reportable side effects and adverse reactions and when to call the physician
  • Provide support, resources and guidance for the caregiver as well as the patient
  • Increase contacts/calls with high-risk patients, our “frequent flyers”
  • Use home care resources to educate patients and their family on new procedures or information on their diagnosis and treatment as outlined by their provider
  • Provide community resources for the elderly and disparate population to set them up to succeed at home, e.g., Meals on Wheels, transportation services, child/elder care, etc.

 Clinician Education

  • Provide staff with health literacy training including “teach back” methods for educating patients (for example, the “Ask, Tell, Ask” method outlined in the Institute of Medicine report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis)
  • Provide medication reconciliation list/guidance and have patients explain their medications and fill their medication planner
  • Incorporate morning reports for the support staff to proactively identify patient needs and the need for phone calls to patients from the appropriate disciplines
  • Initiate early referrals to palliative care for education and symptom management
  • Initiate early goals of care and advance directives discussions
  • Incorporate rounding with inpatient multidisciplinary staff to discuss discharge disposition, barriers to care, length of stay (LOS), discharge delays, carve-out days, and follow-up calls for 24-48 hours after discharge
  • Monitor the patient’s treatment based on national standards and guidelines
  • Create disease-site standing order sets, physician profiles, pathways, and guidelines with timelines when appropriate
  • Research opportunities for creating an oncology medical home or oncology ER/urgent care triage process with protocols
  • Develop plan for avoidable ER visits, i.e., constipation, nausea/vomiting/diarrhea, pain and symptom management, etc.
  • Provide assistance with depression screening (beyond NCCN psychosocial distress screening)

To measure progress, what reports and metrics would be helpful?

  • Request 30-, 60-, 90-day readmission report with reason for admission/chief complaint
  • Request ER visit report for chief complaint
  • Monitor timeliness of appointments, tests, and procedures
  • Review with patients reasons for any missed appointment and assist in resolving issues
  • Create performance improvement projects and metrics to support decreasing readmissions and avoidable ER visits

Discuss and prioritize these ideas with your multidisciplinary team and watch your avoidable admissions and ER visits decline.

Of note: Many of the above examples also align perfectly with the Oncology Care Model (OCM) practice redesign approach, value-based cancer care, and oncology medical home initiatives. Partner with your navigator as healthcare transitions to patient-centered, value-based delivery models.


Contributing blogger ACCC Member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.

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