Roger Kelsey Halbert, BSN, SCRN, CNRN, and Kaile Neuschatz, BSN, RN, are nurse navigators at Yale New Haven Stroke Center. Halbert has been a nurse for 10 years. He has served at Yale New Haven Hospital for the past six years, becoming a nurse navigator in August 2016. Neuschatz has been a nurse for seven years, serving at Yale New Haven Hospital. She has been a nurse navigator since May 2016.
Q: What is the most important work you do as a nurse navigator?
Roger Kelsey Halbert: The most important work we do is threefold: identifying and filling gaps in care, anticipating specific needs of patients, and connecting patients to appropriate resources throughout the whole continuum, from their point of entry through all the different phases in the hospital and then onto rehab.
Kaile Neuschatz: We also hope to improve the patient and staff experience by spending more time at the bedside with patients and families and being able to provide support to staff for both the stroke service and general neurology.
Q: What do you like best about your job?
KN: It’s a unique position and offers a different perspective after working at the bedside. One of the aspects I like best is the teamwork — being able to work with so many different people across different service lines and areas of the hospital, both inpatient and outpatient.
The other aspect of that would be the ability to contribute to the patients’ progress. We’ll see patients in the ER when they are acutely ill, follow them into ICU, provide support to their family, follow them while they are on the floors, and help prepare them for discharge. We’ll call them when they are at home. Sometimes we get to see them in the outpatient clinic and witness how much they have improved. We get to see them across the entire continuum of care, which is also very unique.
RKH: We both like — and maybe dislike, to some extent — the unpredictability of our day and interactions with patients. We’ve had to really change our whole framework, moving from time-organized tasks typical of the role of a bedside nurse to a more fluid and ever-changing role, depending on what assistance patients might need. There might be a complicated issue that comes up which takes the rest of the day or there might be minimal interaction needed one day, allowing us to divert our attention elsewhere.
Q: What value do you think nurse navigation provides?
RKH: The biggest contribution we make is improving care across the entire continuum. There are so many different levels of care and different environments. It can be extremely frustrating for patients and their families to navigate through these levels and feel like they are starting at square one at each specific level.
The fact that there’s a nurse navigator who is helping coordinate all the different players at all of the different levels of their care is something patients and families be aware of. But the fact that they do not encounter problems and ultimately experience smooth transitions of care is probably the greatest value we add to their whole experience.
KN: We’re able to address the gaps in care. We have excellent staff throughout the organization, but there isn’t really anyone specifically designated to address handoffs between the different areas. We’re uniquely positioned to be able to help ensure transitions are smooth and reduce the risk of aspects of care being dropped, hopefully improving the patient’s treatment.
We also can be a hub of communication. We may not know the answers to all of a patient’s questions, but we know a lot of the people across the hospital, so we can help connect patients with the resources they need.
Q: Can you share a patient story or experience that demonstrates the value of nurse navigation?
RKH: We’re a comprehensive stroke center and telestroke hospital. We have eight community hospitals that rely on telemedicine to have 24/7 access to our vascular neurologists. Many times, based on telestroke assessments, patients are emergently flown to our hospitals for evaluation for a mechanical thrombectomy, which is one of our two stroke interventions. When this happens, there are numerous players involved.
There was an instance where a patient was coming from a far corner of the state. Since we responded to the code in the ED, we met this patient at their point of entry. I took care of my navigator responsibilities, which included uploading imaging from the first hospital, coordinating a CT scan, taking the patient to the interventional radiology suite, giving the handoff report to the nurse and anesthesia, seeing the patient in the ICU, coordinating information with their family, and following her through her entire hospitalization, which included a valve replacement. I then arranged follow-up for her, and called her at rehab and when she was home. I ended up developing what was a 2-3 month critical relationship with this patient. I was a face, name, and voice she recognized from the time she came in to the time she went home.
That’s the kind of interaction I did not experience in the ICU while working on the floor as a bedside nurse. This scenario describes the uniqueness of this type of relationship with a patient.
KN: There was another patient Kelsey and I were both involved with. This patient was hospitalized with a stroke who then had another stroke while he was an inpatient. He and his wife were both very anxious. This experience was very new to them. He was being started on a new blood thinner that required lab draws, and it was a lot of information to take in. I think the wife was very overwhelmed. Since we can choose how we allot our time to patients, I was able to spend time with the wife at the bedside, reinforcing education, talking about follow-up, providing support, and often just listening. The patient and family had a unique religious and cultural aspect to their care, and we were able to incorporate that as well.
We were lucky enough to see the patient and his wife when they came into the outpatient clinic. They were having trouble with their medications. They came into the clinic early in the day, but I was able to run over there from another area in the hospital. The wife and patient recognized me, and I could immediately see them becoming more comfortable. Kelsey came over as well. We were able to provide education on a new medication in the waiting room of the clinic. We had the time to be able to provide this service, which is a unique aspect of our role.
Q: What is your biggest challenge as a nurse navigator?
KN: One of our biggest challenges is also one of the best aspects of the job. Since we cross so many service areas — we’re involved in pre-hospital, emergency room, ICU, inpatient, and then outpatient care, there is a lot to learn, not only about stroke and neurology, but about how the health care system works and how to get things done, who to call, and how to document in these various situations.
We each came from one particular unit where we were “experts” in that unit’s care. Now since we’re exposed to so many different aspects of care, there’s constantly so much to learn, which is a challenge but also a fantastic part of the job.
RKH: One of the challenges we’ve faced is because we are a comprehensive stroke center, there are a lot of metrics we must maintain and a lot of data we need to provide. It’s been challenging to quantify our impact on the service line. It’s easy to qualify it, but to have that translate to numbers on a spreadsheet and show, from a financial standpoint, the value of our hours of work has been a challenge. We have every confidence that what we do is worth it, but it’s difficult to translate that statistically.
Q: What do you see as ways or opportunities to improve nurse navigation?
RKH: We’ve seen the benefits of multiple navigators. The more navigators you have available, the more impact you are likely going to have on your specific service.
Our navigator model is probably different from other facilities that have used nurse navigators for stroke in that we cover all aspects of care — inpatient and outpatient — as opposed to relegating navigators to a single unit. That presents challenges, but also makes us a lot more effective. We can work on some things together and some things independently, as opposed to having something very regimented. That requires manpower. We’re seeing how a facility of our size would really benefit from the addition of a few more navigators. That would be a much more ideal workforce.
Q: How do your colleagues view nurse navigation and care coordination?
RKH: We have achieved the reputation of “miracle workers.” Since we have a great track record of getting some very difficult tasks done, the assumption is that we can do anything. I think there’s an argument to be made that there isn’t anything we haven’t been able to do yet.
KN: I would agree. We’re really lucky that we have incredibly supportive managers and support from the medical physician team. That’s something that a strong navigation program needs —supportive leadership that will encourage involvement in various projects.
Q: What would you say to an organization that is contemplating whether to implement a nurse navigation program?
RKH: I think our message would be to do it. Kaile started the program without any formalization or a template. A lot of the things we do are considered tried and tested by her, and we’ve been quite successful.
KN: Definitely do it. The health care system is very fragmented and has become very expensive. If you think broadly from a hospital administration perspective, I think we help improve the patient experience, prevent readmissions, increase education — the benefits are exponential. I also think that it’s applicable to other diagnoses and service lines besides stroke.
If you move ahead with implementing a program, don’t expect it to be easy. A nurse navigation program requires time to integrate into your current practices. It also requires needs assessments to identify gaps in your particularly institution and you must work to determine how a nurse navigator might be able to address them.
RKH: I feel it’s important that navigators be nurses as opposed to lay or unlicensed individuals. Even though we’re not bedside nurses any more, the knowledge and experience we have from being nurses and serving as patient advocates puts us in a unique position to recognize the needs of patients that other people might not, especially if they weren’t health care providers. We really see the efficacy of having a nurse in this role.
Q: What do you hope for as the future for nurse navigation in the United States?
KN: I hope the position becomes more visible. When we first started here, it was a brand-new role. That brought with it some confusion when we were working to explain what we do.
If nurse navigation is implemented more broadly, people are more likely to know we exist and understand what we can bring to an organization. I always hope that medicine will take a more holistic perspective. I think nurse navigators fit nicely into that model.
RKH: In a perfect world, we wouldn’t need nurse navigators because there wouldn’t be fragments in the health care system. We would have a system geared more toward preventative medicine, which would help reduce the current high acuity and frequency of disease.
Since that’s not going to be the case any time soon, I would like to see nurse navigators used as a resource for more community outreach and education. That comes down to more manpower and facilities realizing the different types of services navigators have to offer.