The purpose of this blog series is to describe the concept of health navigators. In the first blog, I defined the basic role of health navigator. After having a few conversations with colleagues, I decided that it is time to write a blog about what role the health navigator does not play in the health care system. Some nurses have commented that health navigators should not work in hospitals because they will not have clinical training. Other colleagues have mentioned that health navigators may never find jobs, because no one knows how their role fits into the health care team. Now, you see the reason for writing this blog about the role of health navigators on the health care team.
My colleagues are correct. Health navigators lack the clinical background to be licensed to treat patients and health navigators are not employed as home health aides or certified nursing assistants. So the question remains: What is the role of health navigators on the health care team?
Before answering this question, let’s take a step back and review the impact of the Patient Protection and Affordable Care Act (PPACA) issues related to decreasing the 30-day hospital readmission rate among Medicare patients. Since its effective date in 2012, Section 3025 of the PPACA has targeted the high readmission rates by reducing payments to hospitals for Medicare beneficiaries readmitted within 30 days of a previous discharge from the same hospital including the applicable conditions of acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). In 2015, the list is extended to include acute exacerbation of chronic obstructive pulmonary disease (COPD), elective total hip arthroplasty (THA), and total knee arthroplasty (TKA) in 2015. Unlike other new programs created by the federal health law, the readmissions program offers hospitals no rewards for improvement or the opportunity to opt out. Effective October 2015, Medicare is increasing the final maximum penalty to a 3 percent reduction for all readmitted patient stays. The national average of readmission rates is 19% and in 2013, 53% of U.S. hospitals sustained penalties. As PPACA penalties increase, hospital administrators give greater scrutiny to all readmission costs. It is therefore critical to reduce Medicare patient hospital readmissions.
With this PPACA information in mind, the discussion starts with a focus on the role of health navigators in hospitals. Frequently, hospitals declare a chronic shortage of licensed physicians and nurses to adequately staff the insufficient number of hospital beds. This equation results in a vicious cycle: a) Low staffing of licensed health care personnel leads to high patient acuity to health care staff ratios; b) high patient acuity ratios leads to longer work hours, greater medical errors, reduction of quality patient care, increase in PPACA penalties linked to high patient readmission rates; c) overworked clinical staff leads to resignations and chronic shortage of licensed nurses and physicians – thus the cycle continues. When health navigators are inserted into the hospital care team, the problems associated with a shortage of licensed clinical staff is not solved; however, a few of the other problems might be reduced. Let’s propose the following case study.
Mary Smith, 76 years old, was admitted via ambulance with a fractured femur and moderate COPD. She lives with her husband, Charles (age 82). They have been married for 52 years and have lived in their one-story house for the last 40 years. They have no intention of moving at this time. Mary had surgery to repair her femur followed by four days of physical therapy. She is walking well with a walker and still needs pain medication at night. The hospital social worker stopped by yesterday for a brief assessment. Mary stated that she wanted a home health aide daily for the first few days after discharge. The social worker entered this request in the EMR for Mary’s physician. Mary’s physician stopped by around 6:00 a.m. and told her that she would be discharged later that morning. Mary was not completely awake during his visit. He wrote a few prescriptions and told Mary that the nurse would go over everything after Mary ate breakfast. He also mentioned that he would see her in his office in about seven days to remove the incision staples. Mary called Charles. He arrived in time to hear the nurse review the discharge orders and the two prescriptions of antibiotics and pain pills. The physical therapy assistant delivered the rented walker and the transporter was called after Charles helped Mary get dressed. On the way home, they dropped off the prescriptions at the local pharmacy for a pick-up later in a few hours. Once at home, Charles pulled into the garage and helped Mary out of the car. Using her walker, they both realized that there are three steps without a handrail from the garage into the house. With only one step into the front door, Mary was forced to walk much further to enter her home. She rested while Charles returned to the pharmacy. While he was gone, the home health agency called and told Mary that her Medicare supplement did not approve the request for home health. Mary was disappointed but her leg was hurting too much to continue the conversation. Charles returned and Mary took a pain pill. Later in the afternoon, she needed use the bathroom. Charles helped her, but they realized that the walker did not fit through the bathroom doorway. They decided that she could walk into the bathroom, lean on the vanity and inch herself a few feet to the toilet with Charles behind her for balance. However, due to the pain medication, being sleepy and only leaning on the vanity, she missed a step. When she began to fall, Charles was unable to maintain his balance. Mary fell. Charles called 911 and she was readmitted to the hospital.
Now let’s review the same scenario with the pre-discharge services of a health navigator employed by the hospital. The health navigator would: a) meet with Mary and Charles in the hospital two days prior to discharge; b) meet Charles at their home to determine steps, lighting, scatter rugs, access through bathroom doorway using a walker, height of bed and toilet, etc.; c) request that physical therapy teach Mary how to negotiate a few stairs with her walker; d) order a bedside commode since the bathroom door was too narrow for her walker; e) give Charles the prescriptions to fill prior to discharge; e) call several home health agencies to negotiate health insurance coverage for a few days of service; and f) move the physician’s follow-up appointment within three days after discharge rather than seven days. These non-clinical actions would have likely kept Mary from a readmission thus saving her additional pain, suffering and financial burden. In addition, the hospital would not have been accessed a PPACA penalty for Mary’s readmission with 30 days.
Although health navigators are not intended to solve the numerous problems facing hospitals, employing health navigators improve the chances of reducing Medicare hospital readmission rates. The health navigators will have time to sit and carefully listen and access the challenges of patients and caregivers. They will make home visits prior to discharge, arrange transportation for follow-up appointments, verify that prescriptions are understood and filled, and note simple suggestions that might be missed among other over-burdened health care team members. It should also be noted that reducing the rate of Medicare readmission by one or two patients annually would pay the salary of a health navigator working in a clinical setting.
Kay Perrin, PhD, MPH, is an Associate Professor and Assistant Dean for the Office of Undergraduate Studies at the University of South Florida, College of Public Health. Dr. Perrin’s research focuses on adolescent health with a special interest in teen pregnancy. Dr. Perrin also serves on several community boards in the Tampa Bay Area. Dr. Perrin is the author of four titles from Jones & Bartlett Learning: Principles of Evaluation and Research for Health Care Programs, Essentials of Planning and Evaluation for Public Health (both published in 2014), and the upcoming Principles of Health Navigation, available in early 2017. Follow Kay Perrin on Twitter @KayPerrinPhD or watch a webcast of Dr. Perrin’s October 2014 Webinar on Teaching Health Research, Program Planning, and Evaluation.