Nurse Navigator Program Helps CHF Patients Find Their Way

June 4, 2024

Nurse Navigator Program Helps CHF Patients Find Their Way

By Matt Phillion

Ensuring medication adherence among patients with chronic conditions such as congestive heart failure (CHF) remains a critical challenge. The industry has seen therapeutic advancements, but half of CHF patients are struggling to keep up with their prescribed medications—leading to adverse clinical outcomes, increased hospitalizations, and higher mortality rates.

One organization has pioneered a program aimed to empower patients with CHF and their families to navigate the complexities and challenges of their illness. Magnolia Regional Health Center has created its new Nurse Navigator program, intended to create seamless integration between prescription data fill—an important factor for prioritizing patients for targeted interventions.

Central to the program is efficient access to clinically actionable medication history, which enables Nurse Navigators to identify and engage CHF patients during hospitalization, and enables personalized counseling, medications reviews, and identification and assessment of barriers to medication compliance. Magnolia partnered with DrFirst to access medication history data for this patient population.

In the first seven months, Magnolia enrolled 361 patients and saw significant improvements in prescription fill rates across all vital medication categories outlined in the guideline-directed medical therapy (GDMT) for CHF patients. Specifically, they saw improved adherence rates with the inclusion of sodium-glucose cotrasporter-2 (SGLT2) inhibitors, which aligns with the updated 2022 treatment guidelines.

“The biggest challenge with this group of patients is medication adherence,” says Brooke Brown, RN, Nurse Navigator with Magnolia Regional Health Center. “We can prescribe all the right medications, but if they’re not picking them up, they’re not doing any good. When they’re readmitted or go to a clinic because they’re not feeling well, it’s because, well, they’re not taking their meds. And why aren’t they?”

It’s solving for the “why” that is at the crux of the program, Brown notes.

“When we do a medication reconciliation with them, we ask why. ‘Do you have any barriers?’” she says. “’Can you afford the medications? Do you have insurance? Do you have transportation?’”

Often for patients, other needs come before their medications. So there’s a need to close the gaps that interfere with these patients staying on their medications, whether it’s an affordability issue, access to the pharmacy, or any other issue that might be in the way.

A three-step process

Typically, gathering up-to-date medication history for patients between visits involves making phone calls to patients, providers, caregivers, family members, and pharmacies. In the worst-case scenario, this process can take hours for a single patient. Using DrFirst to gather medication history data for CHF patients in near-real time, the Nurse Navigator program follows a three-step process for addressing patient needs following the initial diagnosis of a patient with CHF.

“We then get called in for a consult, which is built into our system. I’m given a printed medication reconciliation form in collaboration with their doctor and RN, and we look at the GDMT guidelines for what’s recommended for this group of patients,” says Brown. “I’ll go to the patient’s room, introduce myself and the program, and explain what it means to them. Everyone has been very receptive to someone sitting down with them to help them bridge the gap between inpatient and outpatient care.”

She or another Nurse Navigator review the medications with the patient and their family and discuss their barriers to compliance. They set up necessary follow-up appointments, or review existing follow-up appointments, and verify their contact information.

“We may have old phone numbers, or the patient may prefer we call their daughter instead of them directly, for example,” says Brown.

Additionally, they reconcile which doctors the patient will be dealing with: is there a specific cardiologist or PCP? This ensures they’re making those follow-up appointments with the right doctors and offices.

“Once they’re enrolled in the program, we’ll update their contact information and take note of their current GDMT status,” says Brown. “If, for example, they’re supposed to be on four medications, but they’ve only got two, we talk that through.”

They then document any follow-up appointment and potential barriers, and if necessary, loop in social workers or other assistance.

That’s just the first step. Next, within 72 hours (usually sooner), the Nurse Navigator will call and perform a checkup on the patient, comparing that initial documentation and discharge summary to look for any gaps that were addressed prior to discharge or if anything was not documented accordingly.

“I’ll refresh their medication history using DrFirst’s population health management solution and see what was prescribed, and then verify if they’ve picked that medication up. This also is a way to hold the patient accountable for their own care,” says Brown. “I already know the answer to that question from their medical record. It gives us real-time data about their adherence.”

They then schedule any follow-up appointments.

If the patient is unresponsive to the check-in, they get three chances to respond. (Patients who refuse to respond are removed from the program.)

From there, the Nurse Navigator will make note of any gaps or missing medications, or if they’ve found the patient cannot, for example, tolerate one of the medications prescribed, they will document any contraindications for that medication and if any corrective action is taken.

“That’s the most time-consuming part,” says Brown. “Step three is following the patient for 30 to 60 days, depending on their needs, calling once a week or so depending on the patient. Some people want to take the bull by the horns and improve their health, but others need more help with that process.”

The check-in calls help the program examine the data and see from month to month if patients are refilling their medications, or if adherence is lagging, and to assess who needs to be called more often or monitored more closely.

Involving the right people to help

The program works closely with case management and other departments to help with patients who experience barriers to medication adherence that can be resolved through access, such as transportation. They also work toward addressing the financial burden of medications was well, where they can.

“Some of these medications are expensive, and insurance is not always covering them, so we work to get samples or find prescription assistance. Our social workers and case managers do a wonderful job identifying patients who qualify for those programs,” says Brown.

Patient response to the program has been universally positive, Brown notes.

“When you’re in the hospital, you have all these services at your disposal. If you don’t know what to do, there’s someone there, from nursing to respiratory care to case management to your own physician, but once you go home the question is ‘Now what?’” says Brown. “The Nurse Navigator program offers one initial point of contact to bridge inpatient to outpatient, someone who can call your cardiologist or PCP to see what they have to say about what you’re experiencing.”

For a patient who is already not feeling well post-intervention, that single point of contact can be a pivotal way to transition to home and help them be accountable and independent.

“Everybody wants to feel like someone cares and wants them to get well,” says Brown. “That’s our biggest thing. We want to take care of patients not just in the hospital but as outpatients as well.”

On the staff side, Brown says the team couldn’t have imagined how well the program has gone over.

“For the physicians, it’s an extra set of eyes. Someone is looking and going over the medications prescribed. We all need help from time to time, and we’ve had such amazing results so early on, particularly with fill rates,” she says.

While the program is still young, these early successes have turned their eyes to the next steps.

“We want to continue with data collection and analysis, looking at those readmission rates,” says Brown. “Hopefully this will be one of those programs we do not only for heart failure but for any disease process, whether it’s diabetes, COPD, or any of the chronic issues we see bringing our patients back to the hospital.”

In the end, it’s about getting everyone on the same page in caring for the patient, from the physicians to the patients themselves and everyone in between.

“We want to help patients be the best they can be, in a way that’s safer, more effective, and more efficient,” says Brown. “It’s what we’re looking for in the quality world. Our biggest complaint we’d hear from patients is ‘I don’t know what to do when I leave the hospital.’ And with the push to get patients home faster and faster, we’ve got to be ready for them when they get home. That’s the main thing we do, to be able to hold their hand as soon as they get that discharge order.”

Check out the article on PSQH website.