Rethinking the Care Coordination Strategy

Hospitals like Magnolia Regional Health Center are adding nurse navigators to the care management team to focus on specific clinical pain points. The result is a reduction in rehospitalizations and better medication management.

Unnecessary readmissions are one of the costliest pain points in healthcare. Hospitals are addressing that challenge by taking a fresh look at care coordination.

At Magnolia Regional Health Center in Corinth, Mississippi, leadership was staring at a high readmission rate for patients with congestive heart failure (CHF), which negatively affected clinical outcomes as well as reimbursements. They decided to focus on medication adherence, which negatively affects roughly half of all CHF patients.

To handle this task, they turned to nurse navigators.

“The strategy around reducing heart failure readmissions, we felt, was one that required hand to hand combat, and in a multifaceted approach,” says Ben Long, MD, director of hospital medicine for the 200-bed hospital. And so that is where we chose to deploy our nurse navigator [to help] us reduce those readmissions.”

The strategy is relatively new in healthcare, and one that requires a different take on how patients and their families interact with the care team. Magnolia created a new program that assigned nurse navigators who would access a CHF patient’s medication data (through digital health technology supplied by DrFirst) and meet with the patients at discharge and between follow-up visits.

Long noted that Magnolia hadn’t had any nurse navigators in the past, so it took a little time and effort to define the parameters of the position. They had to “operationalize navigation,” he said, to complement and not overlap other strategies/responsibilities, identifying the navigator’s scope of practice and responsibilities.

 “The intended function and reality often don’t look very similar,” he added. The primary difference between this and the more common case manager, though, was important: Nurse navigators could work more easily with clinicians, filling in care management gaps that might go unnoticed.

In this case, nurse navigators were focused on one topic: Medication management. With access to a dashboard detailing the patient’s medication history, they could counsel both patients and their families on how to stay on top of their prescriptions.

Magnolia leadership established three goals toward improving patient outcomes: Close communication gaps within the care team, help patients overcome barriers to their own care, and reduce complications or exacerbations related to their medical conditions through proactive intervention.

Focusing on CHF patients was especially important, Long says, because treatment guidelines have been updated at least three times since 2022.

According to hospital officials, over the first 10 months, the nurse navigator helped the hospital reduce 30-day readmission rates for CHF patients from almost one in every four to 15%, while boosting medication adherence by 10% for patients who’d had at least one consult and 38% for those who’d had four or more follow-ups.

The program has been in place roughly three years, and Magnolia now has three nurse navigators, all hired internally. Executives say they’re pleased with the results and are considering expanding the program to encompass more chronic care patients, such as those living with diabetes and COPD.

Long says they’re constantly evaluating the program to see where nurse navigators can impact care management.

“There’s a difference between adherence and compliance,” he points out. “Does this change behaviors for the better? Compliance can often be thought of as simply doing what you’re told, but we really want patients to be adherent … which assumes compliance but also active engagement in one’s care plan.”