Teresa Gager, BSN, RN, CCRN-K, is the heart failure navigator at Tallahassee Memorial HealthCare in Florida. She began her role as heart failure navigator in March 2015. Gager has 30 years of experience as a registered nurse and 26 years as an ICU nurse.
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Q: What is the most important work you do as a nurse navigator?
Teresa Gager: One of the most important roles of the heart failure navigator at Tallahassee Memorial HealthCare is that of educating the patient and their family. Anxiety, fear, and a sense of loss of control are very common emotions that are experienced the first time the term “heart failure” is heard. These patients need a compassionate and knowledgeable navigator who can assist them in understanding what a diagnosis of heart failure means, how it is treated, and what it means for them when they go home. By providing the patient and family with the educational tools they need to know how to manage their chronic condition, the navigator helps to decrease the patient’s anxiety level and helps to return a sense of control to the patient regarding their condition.
The nurse navigator works in conjunction with a multi-disciplinary team (dieticians, case management, bedside nurse and physician) to reinforce the key concepts necessary to have a successful transition home and to prevent readmissions. Topics that need to be covered during educational sessions with the patient include: the importance of daily weights, following a low-sodium diet, maintaining a fluid restriction, compliance with medications, being able to recognize the signs/symptoms of worsening heart failure, the importance of keeping follow-up appointments, and when to call the physician. This information is given in several, small sessions utilizing the “teach-back” method to ensure the patient and family understand the concepts that have been taught. Written heart failure action plans, daily weight logs, and a digital scale are provided to patients to support them in their transition from hospital to home.
Q: What do you like best about your job?
TG: One of the aspects of my role as a nurse navigator is being an advocate for the patient and family. This is done by listening to their concerns and assisting them in the coordination of their follow-up care.
The heart failure navigator provides a risk screening for potential readmission on all heart failure patients on admission. If a patient is at high risk for a readmission, the navigator begins the referral process for services the patient may qualify for such as transitional care, home health care, and/or case management referral for inpatient rehabilitation on discharge. Experience has shown that a patient leaving the hospital with an appointment in hand is more likely to keep that appointment. The nurse navigator ensures this is done by scheduling the patient for a post-hospital follow-up appointment in the Tallahassee Memorial Heart Failure Clinic within 7-10 days of discharge.
Another important role of the nurse navigator is that of communication with the patient’s primary care provider (PCP). Along with the discharge summary, the nurse navigator communicates to the patient’s PCP via a handoff form that includes information regarding the patient’s clinical status on admission, discharge, and at their follow-up appointment at the heart failure clinic. This sheet also communicates information regarding the type of heart failure the patient has, precipitating factors of this admission, tests that were performed during the current hospitalization, and medications being given to the patient’s specific heart failure plan. This communication is vital to the quality and continuity of care for the patient.
Q: What value do you think nurse navigation provides?
TG: Patients and families need a caring, compassionate guide to help them as they maneuver their way through what can be a complex healthcare system at a time in which they are physically and emotionally vulnerable. The nurse navigator can be the person that provides crucial support during this challenging time. Nurse navigators can look at the situation from an objective position and steer the patient and family to valuable resources that the family may not know exists.
Q: Can you share any patient stories or experiences that demonstrate the value of nurse navigation?
TB: In my role as heart failure navigator at Tallahassee Memorial HealthCare over the past two years, the names of several heart failure patients have been etched into my memory. In the first few months of our program, several of these patients had been readmitted frequently. One such patient had been admitted multiple times for heart failure, atrial fibrillation, and diabetes. His primary cardiologist was approached by the nurse navigator and it was requested that he be enrolled in our heart failure clinic program that is designed to see our high-risk patients once a week for the first four weeks, and then as the physician felt was necessary to optimize medications and treatment. The primary cardiologist agreed, and on discharge, this patient was enrolled in the program. He has been coming to his appointments as scheduled and has only been admitted to the hospital two times since enrolling in the program.
Another example that has shown how valuable nurse navigation can be is having patients smile and say “thank you” to the nurse navigator for referring them to the program because they now feel like they are “living” again.
Q: How do your colleagues view nurse navigation and care coordination?
TG: Tallahassee Memorial HealthCare knows the value that nurse navigation can afford an institution. The benefits to the institution result in financial savings by reducing readmissions, quality resource allocation, and increased patient satisfaction. The navigator is the “caring hands” of the facility. The organization becomes a part of the family that is providing care and that a patient knows they can depend on in difficult times. Facilities that promote the use of such caring, compassionate ambassadors will reap the benefit by becoming part of the patient’s care team instead of just a place that a patient goes in order to receive care.
Our facility and our colleagues have embraced the services that are provided by our nurse navigators and have offered overwhelming support of our efforts by partnering with us in the care of the heart failure patients seen at our institution.