Our monthly COPD column explores the clinical role of the COPD navigator, which is intended to oversee patient care, education and discharge for all COPD patients admitted to the hospital with the goal to reduce 30-day readmissions.
By Lisa Spear
Chronic obstructive pulmonary disease (COPD) is hard to navigate for many patients, who often leave the hospital with a new diagnosis, ill equipped to handle the obstacles that come with it. They end up returning to the emergency room, time and again, frightened and unable to breathe.
More and more hospitals across the country are creating new positions called pulmonary disease navigators. These individuals are patient advocates that help guide people through the healthcare system and educate them on their condition. New programs like these can help, but it’s important to make sure that these initiatives are designed correctly, said Michael Nay, MBA, RRT, senior director for respiratory care services of Novant Health in North Carolina.
He suggests that medical centers look beyond in-patient education. Often the reason for a patient’s decline in health is related to their home life or personal circumstances that healthcare professionals might not always think to ask about, but should. If a patient thinks they have to choose between groceries and medication, they will likely skip taking their medications. They might not have a primary care provider, so navigators can help them get one. Transportation can be an issue. Patients might not have a ride to pulmonary rehab, so the navigator can guide them to a social service agency that offers rides.
A large part of the navigators’ jobs at Novant is often just to ask the right questions to determine how best to serve the patients and figure out how to get them to the resources they need. Sometimes these questions go beyond medicine and respiratory therapy, but they can make all the difference.
After getting to know the patients, pulmonary navigators create individualized plans for each person for when they leave the hospital.
“We want to make sure they are super clear on when they should be contacting their pulmonologist or primary care provider and why it is so important that they are making those outreaches early and not waiting,” said one pulmonary disease navigator, Margo Bell, RRT, who works with patients at Forsyth Medical Center in North Carolina.
“This patient population loves to sit on their hands and think that their breathing is going to be better tomorrow or the next day and it seldom plays out that way,” says Bell. In the area where Bell works, COPD is widespread, so this program was all the more important to get off the ground.
Navigators like Bell come to patients’ bedsides and spend time with them that pulmonologists or other physicians might not have. They work to understand each patient’s needs. They work to build relationships. “We are some of the first people who actually share with them honestly what COPD is,” said Bell. Since the start of the program, the Novant Healthcare System has seen a substantial decline in hospital re-admittance, said Nay. Other facilities throughout the country have seen similar results.
Intermountain Medical Center in Utah, for instance, has also been successful in keeping COPD patients out of acute care for longer periods of time, said Vrena Flint, RRT, BSRT, MBA, central region respiratory director.
When administrators agreed to launch the program about 15 months ago, 30-day re-admittance rates for COPD patients at the hospital were close to 20%. After getting the program running, rates reported from November 2017 to December of 2018 are at 11%, according to data provided by the center.
Before starting the program, the Intermountain Medical Center began with a two-week trial period. During this process, they kept close tabs on productivity and revenue to determine if the program was financially feasible. “We knew that the program was really important, but in order to sell the program, we wanted to make sure that we could be budget-neutral,” said Flint.
When the medical center administration got on board, the team started drafting protocols, checked billing compliance and drafted job descriptions and a pay scale. They also investigated methods for recording patient outcomes. So far, Flint said, “We’ve had really excellent feedback from patients.”
Each pulmonary or COPD navigator program is unique, but all of them have a shared goal of patient advocacy and education. When Bell meets with a new patient at Forsyth Medical Center, she starts by reviewing the physiology of the disease. During these initial moments, she makes sure to hand them a folder that might include guides on smoking cessation resources, information pamphlets on COPD, and her business card.
Another COPD navigator, Maida Lowery, RRT, who works at Kaiser Permanente in Los Angeles, California, said that she teaches patients breathing exercises and how to manage their medication. “I try to make every moment a teaching moment,” she said.
Another element of developing a successful program is making sure all relevant medical personnel are informed of the program. At Intermountain Medical Center, staff developed a “stop sign” system to communicate to nurses when a patient still needs to meet with a pulmonary navigator. They hang a bright yellow sign in the patient’s room to communicate to nursing staff that the patient is not ready to be discharged and still needs to meet with a pulmonary navigator, said respiratory manager Emily Allison, RRT, CPFT, BSRT, MBA. “Get the message out, so the nurses as well know that this is something that we are doing. We are trying to impact these patients in a positive way” said Allison.
Ongoing follow-up and reinforcement is also essential. If patients return to the hospital, Bell gets an alert on her computer, so she knows instantly when they are re-admitted and can work with them to understand why and try to solve whatever problem they may have.
When patients return to the hospital for pulmonary rehab at Kaiser, Lowery makes sure they know how to use their oxygen tanks properly and reviews their medication. “This helps them be successful when they are at home,” she said.
Pulmonary and COPD navigators may also have more time to spend with patients than many physicians. When Bell first meets with patients, she makes sure to give them at least 30 minutes. “We build rapports with these patients, they open up and tell us things that they may not share with a new doctor that’s taking care of them at the hospital,” said Bell.
At Forsyth Medical Center, navigators have access to iPads that they can hand off to patients to watch videos on COPD related topics. They have plastic models of lungs, so the patients can have a visual representation of their anatomy. After the initial consultation, Bell will visit the patient in their hospital room the next day to spend another 20 minutes speaking with them.
Another key aspect of creating a successful program is hiring the right people. For Nay, this means having a strong respiratory therapy background. Ideally, he likes to hire pulmonary navigators who have experience in an acute care setting.
Since there is a lot of independence in these jobs, he wants people who have demonstrated that they have the ability to make the best use of their time to interact with as many patients as possible, he said.
It’s no surprise that since launching these programs, hospitals have seen better patient outcomes and improved patients’ quality of life. “Our patients tell us through surveys that they have a better understanding of their disease process, how to utilize their medications, and how to take care of themselves when they leave our facilities,” said Nay. “Just overall, there are countless stories from our patients and their families about how we have helped them better take care of themselves.”
“We continue to revamp the processes,” said Nay. “We’re trying to stay nimble.”
Lisa Spear is associate editor of RT. For more information, contact [email protected].