Published on March 19, 2012

Nurse Navigator Impacts Readmission Rate

Mary Hurley described community care navigator Missy Grubbs as her guardian angel.

Read Karrie Britt’s entire story from WellCommons.

Mary Hurley described Lawrence Memorial Hospital’s new community care navigator Missy Grubbs as her guardian angel.

Hurley, a Lawrence resident, suffers from chronic obstructive pulmonary disease, a common lung disease that makes it difficult for her to breathe. Hurley, a lifelong nonsmoker, said she contracted COPD after years of working in restaurants where she was exposed to second-hand smoke.

During the past year, she has been hospitalized 11 times at LMH. She said she isn’t strong enough to cough up the mucus that forms in her lungs and it gets stuck.

“Let me tell you — it’s scary when you can’t breathe,” she said.

During Hurley’s last hospitalization in February, Grubbs made connections to get her a new breathing apparatus at home that she says changed her life.

“It’s a godsend,” Hurley said. “Since I’ve had it, I have slept all night long. I feel rested. I feel good.”

Grubbs learned about the home ventilator during a “Transitions of Care Forum.” LMH began hosting these quarterly forums about a year ago to provide better care coordination within the community. The meetings are attended by a variety of providers, including those in hospice care, home health, pharmacy and medical equipment.

Grubbs, a registered nurse, said she was unfamiliar with the company and its machines until a representative attended a couple of meetings.

Finding the equipment is just one way Grubbs has helped Hurley. She also found Hurley a new primary care provider, and now calls a couple times a week to see how she’s doing and to go over her medications. Her goal is to keep Hurley at home and out of the hospital.

Since Grubbs was hired as community care navigator last summer, LMH has seen its admission rate drop 68 percent for the 87 chronic disease patients that she is working with.

Common reasons for readmissions

Two years ago, LMH began making a concerted effort to lower readmission rates for several reasons: to improve patient care, reduce costs incurred from the low-income and uninsured populations, and because it will be penalized financially by Medicare in 2013 if its rates are higher than the national average.

“We know some patients — no matter what we do — are going to readmit,” said Linda Gall, director of care coordination. “We are really targeting and trying to decrease preventable readmissions.”

She said not only are uninsured and Medicaid patients at higher risk for readmissions, but so are patients with certain chronic diseases: congestive heart failure, acute myocardial infarction, pneumonia and COPD.

So, Grubbs focuses her efforts on those populations. What she does is visit with them while they are in the hospital and then make as many follow-up calls as needed. She typically calls twice a week for at least a month, but she said some patients need much more assistance.

Grubbs tries to make sure they have the resources they will need at home, such as medication, equipment, transportation and meals. She also will make sure they have a follow-up doctors appointment; she often makes them herself.

After taking a thorough look at readmissions, LMH found that many patients would end up back in the hospital before they saw their primary care doctor because appointments wouldn’t be for two weeks. Now, they work with doctors to get patients in within three to five days.

Another cause for a lot of readmissions was confusion about medications. “Even though it was all written out for them when they were discharged from the hospital, they would go home and then get confused or sometimes they didn’t pick up their medications or sometimes they weren’t taking them correctly,” Gall said.

‘Common-sense solution’

For years, Allison Veeder worked as a nurse in the LMH emergency room. She often saw people who were discharged with no place to go and would end up back in the ER.

Now, she’s working at Heartland Community Health Center, a Lawrence safety net clinic, which provides care regardless of insurance or income. She said the LMH community care navigator has helped close the communication gap between primary care and the hospital.

“It’s a low-cost, common sense solution to one of the biggest, most expensive problems we have, and it increases efficiency,” she said.

Grubbs often refers patients to Heartland Community Health Center.

Veeder said she appreciates being able to get a quick summary of a patient’s status from Grubbs through a phone call rather than searching and sifting through medical information online. And if she has a question, she just needs to call Grubbs. Before, she would have to call several doctors and nurses.

“It’s one of those things after it was created that you think, ‘Why wasn’t this here 10 years ago?’” Veeder said.

LMH has made strides in reducing its 30-day readmission rate. Its latest data compares 2007-2010 to 2010-2011. During that time, readmissions dropped 7 percent for acute myocardial infarction, 9 percent for heart failure, and 1 percent for pneumonia.

Grubbs worked with one patient who had 27 admissions in 2010. In 2011, that patient had eight.

“This is about the patients’ quality of life,” Grubbs said. “People don’t feel good about themselves or just in general when they are always in the hospital. So, I’m here to help.”

Hurley said she felt “like a million bucks,” during a phone interview Thursday. She is thankful for Grubbs’ services and especially for her help in finding the new breathing machine.

“That’s going to save me and my insurance — both, beaucoup money because I haven’t been back to the hospital since I received the machine,” she said.

Nurse Navigator Impacts Readmission Rate

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Phone: 785-505-2931