Care Navigation Nursing Services: Transitions of Care Outreach Support

Posted By: Katharine McQueen Industry,

Providing a healthcare support team for patients when they need it the most involves coordinating and managing the necessary networks to ensure patients receive the right care at the right time and place and with the right provider. The Patient Access Collaborative invited University of Utah Health’s Jennifer Swensen, BSN, RN, Nurse Manager, Care Navigation, to present their approach to navigating transitions of care and patient outreach support.

Swensen explained the Care Navigation Department at the University of Utah Health is a “coordinated care team supporting patients when they need it the most.” The care team is responsible for handling multiple pathways of communication through contact, automated texts, and voice messages. Each year, the department cares for over 2.5 million patients by phone, conducts forecasting and planning for over 3.6 million patient contact interactions, and manages over 2.6 million patients through digital outreach and automated text and voice support.

Improving patient outcomes via optimal care transitions is a top priority for Care Navigation. Operating in a large market, the team expanded their telephone hours to enhance outreach and success. The department remains open 365 days a year and offers a multitude of support options for patients: from outpatient appointment scheduling to nurse triage and advice. In addition to these core services, Care Navigation provides medication management and centralized virtual care. Critical to the success of Care Navigation is Nursing Services. Swensen explained the Nursing Services department is “led by a telephone nurse triage navigation team that utilizes evidence-based guidelines and protocols to guide patients to the right care at the right time.

Nursing Services provides additional support through its care communication team to manage communication regarding medical advice and lab and imaging results. One of the key priorities is to minimize messages to care team pools and providers – and respond to patients in a timely manner. In addition, Nursing Services supports population management to assist with clinical outcomes and address preventable interventions.

Care transitions is a core component of Nursing Services. Swensen identified, “the transitions of care are a coordination of care for patients in hospital, post-acute care, and those transitioning back to home.” Nursing Services best support the transitions of care through patient outreach. Swensen relayed, “the nurses are responsible for making the outreach calls within the 24–48-hour, post-discharge time frame, and with at least 2 call attempts.” Further, they schedule follow-ups with a primary care physician (PCP) within 7 days, handle discharge instructions, and support specialty care visit follow-up. They also offer virtual video transition of care, and recently introduced remote monitoring.

The nursing team is equipped with workflow “tip sheets” to navigate outreach calls, medication and pharmacy management, follow-up scheduling with a PCP, and specialty care. Swensen highlighted the high-level system approach to the transition of care calls and relayed, “this is not a manual approach, but rather, an automated system that collaborates with the multiple caregivers along the patient journey, touching points with the PCP, pharmacist, care manager, and clinic support staff.” 

View Tip Sheet

The system’s automated discharge list of questions is designed to track and capture additional patient needs. Scenarios of these questions include: (a.) Who is helping you at home? (b.) Have you been contacted by home health? (c.) Do you have questions about your medications? (d.) Do you have any concerns or questions since being discharged, and (e.) has your transition of care management (TCM) appointment been scheduled? The system’s queries and answers provide important feedback to further assist Swensen and her team so they can better support patients at the point of call.

Monitoring outcomes is important to Swensen and her team. She expressed: “we love to track outcomes to illustrate what patient population we are [assisting].” Swenson highlighted the outreach support systems the team employs to further assist and monitor patient care and discharge support. These include: a transition dashboard used to track “who is” and “who is not” being reached by phone within the 24-48 hour discharge time frame, as well as a transition dashboard that monitors emergency department return visits and readmissions during the 14-day post-discharge, as well as mortalities during the 30-day post-discharge.    

Swensen emphasized how valuable lessons learned have helped steer Nursing Services to realign the patient outreach processes. Currently, the nurses make all the calls to avoid duplicate work with the pharmacy, and discharge notes are condensed into documentation via standardized forms, which efficiently extract data. To avoid missing reimbursement opportunities, the team now confirms the TCMs are reviewed by the provider and appropriately billed.

The value proposition of University of Utah Health’s Care Navigation is clear. Swensen and her team are improving access to appointments, enhancing communication, and streamlining care transitions.