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

March 24, 2015
by Gabriel Perna
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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?