THE AMERICAN COLLEGE OF CARDIOLOGY (ACC) recently announced the launch of its Patient Navigator Program, which will help hospitals pioneer a team approach to keeping patients healthy and at home after admission for acute myocardial infarction (MI) or heart failure (HF).

Almost 20% of Medicare patients hospitalized for acute MI and 25% of hospital patients with HF will be readmitted to the hospital within 30 days of discharge. Recently, there has been a renewed effort among healthcare organizations, physicians, professional medical societies and government entities to reduce the number of 30-day readmissions among these patient populations.

In an effort to do that, the ACC's Patient Navigator Program has selected 35 participating hospitals, included Huntsville Hospital in Huntsville, Alabama, to pilot programs to develop new or enhance existing processes to reduce readmissions and improve patient care. The program will combine the ACC's National Cardiovascular Data Registry with quality improvement strategies, toolkits, patient education materials, and other best practices from the ACC's Hospital to Home program.

Huntsville Hospital recently completed its initial implementation and assessment period for the Patient Navigator Program. CardioSource World News recently spoke with four team members at Huntsville Hospital participating in the program to find out more about how the program aligns with the hospital's priorities, the members and responsibilities of its multidisciplinary team, and its plans to begin implementing strategies to improve readmission rates and patient outcomes.

CSWN: What is the Patient Navigator Program? How does it work?

ANGIE BATES, CRNP (Nurse Practitioner & Patient Navigator): The Patient Navigator Program is designed to coordinate collaboration between multiple disciplines in the hospital to offer patients and their caregivers a tool set to better manage their disease process at home.

JAMES D. MURPHY, MD (Cardiologist with The Heart Center, Inc.): Right now in cardiology, everybody is thinking about 30-day readmission for post-acute myocardial infarction and heart failure. There is a lot of data out there suggesting some clinical means for improving compliance and reducing 30-day readmissions. Unfortunately, there is also a lot of conflicting data as to whether these measures actually work. We welcome the efforts of the ACC and the Patient Navigator Program in developing programs across the country. This will be a proving ground of sorts that may help clarify what really works.

How does the Patient Navigator Program align with Huntsville Hospital's strategic priorities?

MURPHY: Huntsville Hospital is a large community hospital that is developing a tertiary care footprint. Part of what we are doing as a group is combining all of our patient services, including our outpatient services in heart failure, to try to better care for patients. Nationwide, there is an effort to reduce 30-day readmissions to improve quality of care and streamline care. Huntsville Hospital has already started working towards that goal pretty heavily. The Patient Navigator Program is another service and another revenue stream that allows us to put a specific person in charge of those efforts. We chose Angie Bates very carefully because she does a great job, and we are excited about all that she is going to do for the program.

ARIN ZAPF (Nurse Manager): The Patient Navigator Program aligns with Huntsville Hospital's goal of improving transitions in care by providing the support needed to implement evidence-based initiatives that will improve the outcomes of our patients – initiatives like a more timely post-hospital follow-up visit.

Who is on your Patient Navigator team? What disciplines are involved?

ZAPF: First, we are truly blessed to have such excellent physician support like Dr. Gessler and a physician champion, Dr. Murphy, who is the clinical driver of this program. Our group and our team start with them. Next, we have administrative leaders and nurse practitioners like Angie, who is on the units identifying patient barriers and collaborating with other disciplines, such as case management, to ensure a successful discharge plan. Pharmacy is involved in reviewing medications and will soon have a role with education as well. The team also incorporates clinical nurse specialists, marketing and informatics.

MURPHY: I should point out also that Arin was heading up these efforts for a long time before we developed a formal program. She was the director of the unit that handled our step-down care and she took this on all by herself two or three years ago. She has done a great job of integrating inpatient and outpatient care programs and setting up a high quality team of nurses, nurse practitioners, and physicians.

CARL GESSLER, JR., MD (Cardiologist with The Heart Center, Inc.): The launch of the ACC's Patient Navigator Program was convenient for Huntsville. We aren't starting our quality initiatives because of this program. We were doing this for some time and this program has come along as a nice, parallel, ACC-endorsed program that will help with funding and support.

What are the benefits of having a multidisciplinary team involved in improving transitions of care?

ZAPF: These patients are very complex; therefore, a multidisciplinary approach to address the issues is essential for their success. We have a golden opportunity when these patients are admitted to discover an unmet need, and having someone to identify and navigate this transition is a huge benefit. It also helps to improve the continuity of care between our inpatient and our outpatient areas of service.

BATES: We have been trying very hard to implement the Patient Navigator Program initiatives on our off-cardiology service floors. This approach has created a culture of ownership of the patient as more than a singular admit diagnosis. The communication across disciplines has helped to make an overall awareness that patients aren't just cardiac or GI or surgical. These patients need the opportunity to be provided the tools to manage their care at home. In using a multidisciplinary team, we have been able to inspire that sort of thought process, from bedside nursing through ancillary services to being able to take care of the patient as a whole, whether they have heart failure, acute myocardial infarction, COPD, etc. The navigator role has encouraged a better culture in our hospital in taking care of patients interdisciplinary from floor to floor.

Huntsville Hospital just completed its first site visit. What are some of the things you learned from this visit?

BATES: In preparing for the site visit, it became increasingly apparent that we had a lot of really good people in place doing a good job on a solitary basis. The site visit allowed us to pull those jobs together with a primary focus that illuminated our many strengths, and found an outlet to improve on any weaknesses.

ZAPF: I agree with Angie, the site visit helped us to narrow our focus. There are many practices out there that hospitals like ourselves are implementing, such as the 7-day follow-up, self-care management education, follow-up phone calls, and tele-health scales, and it's difficult to get it all accomplished. The site visit brought our team together to determine our needs and what our next steps should be.

MURPHY: My take home from this was the scope of what the ACC and AstraZeneca are doing. I had no idea how much money they had put into this program, and we are grateful. I also love the idea that the ACC is going nationwide with this. They gave us a very comprehensive evaluation of our site. They gave us our strengths and weaknesses, but then didn't tell us what to do. They asked us what we wanted to do and improve upon, letting us focus on the things that are most important to our hospital.

How do you plan on prioritizing your implementation efforts?

BATES: When they presented our assessment results, we had multiple initiatives to consider. We didn't want to have so many things going that we weren't doing a good job with any one of them. We chose to prioritize based on the highest benefit to the patient, predetermined barriers, and fiscal sustainability.

What are some of the areas that Huntsville plans to focus on?

MURPHY: Even something as simple as record keeping and improving our EMR. We are trying to spread that throughout the hospital and to the outpatient center as well. Secondly, we plan to focus on identifying who these patients are. It is really easy when patients are on a cardiology floor, but it is more of a challenge when the patient is off the cardiology floor with no cardiologist seeing them. That is where Angie has really stepped in and taken over. She is going out and screening people throughout the hospital to identify heart failure patients and get them on a program to help standardize care across the hospital.

What are you looking forward to the most through the implementation of this program?

ZAPF: I think it will be exciting to see what we can accomplish by having a navigator and working with the ACC to track our progress.

BATES: From a nursing standpoint, when we first starting looking at the navigator role and how we would try to help with heart failure and acute myocardial infarction patients, we started talking to other areas in the hospital. One of the things that came out of it was that if we developed processes that work, they should work for every disease process. Even though right now we are focusing on heart failure and acute myocardial infarction, we have an opportunity to develop programs that should seamlessly overlay onto other disease management processes, creating better patient care across the spectrum of hospitalized patients.

MURPHY: Arin had identified two to three years ago that we were missing patients off the cardiology ward. Try as we did, we did not have the funding to attract someone able to take on that role, and we know that is one of our biggest deficits here at this hospital. Because of the funding the ACC provided, we were able to attract somebody of Angie's caliber. She is extremely hands on, very personable and creative, and an outstanding provider of care. She is going to allow us to take this to the next level and, to me, that is very exciting.

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To find out more about the ACC's Patient Navigator Program, visit http://cvquality.acc.org/en/Initiatives/Patient-Navigator.aspx.

Keywords: ACC Publications, CardioSource WorldNews

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