Nurse Navigator Program: Bridging Public Health and Primary Care with Potential to Improve Chronic Disease Outcomes

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Over the past three years, an innovative nurse navigator program has developed in La Plata County (southwest Colorado, population 51,334 in 2010) through the local public health agency. Beginning as two separate, grant-funded programs: a childhood nurse navigator program and a similar senior nurse outreach program. By the beginning of 2012, the program evolved into a ‘womb-to-tomb’ model that serves all ages and has specific disease management, self-care education and coaching components, and a care coordination focus that includes psychosocial and community based resources. The program bridges public health and the health care system to deliver explicit components of the patient-centered medical home (PCMH) modeli including care management, self-care process support, and referral tracking and follow-up with care coordination. The program has secured community-based funding through at least December 2012 and is in an optimal stage of development to conduct pilot research to identify successful processes and outcomes of the expanded, community-supported program. This research will serve to justify continued funding locally as well as justify subsequent larger scale studies to inform programs nationally. To not conduct this research study now would be to miss an opportunity to rigorously study a public  health-based  method of delivering many of the components of the PCMH that can allow smaller, rural communities throughout the country to improve  care delivery  through partnership between public health and health care.

Patient navigation is not a new concept—it is an evidence-based practice in cancer prevention and screening and has been widely used in treatment and survivorship. ii Navigation has also been shown to have positive results in reducing disparities in cancer screening and outcomes and health care access.iii Now spreading beyond the cancer-control field, navigation goes by many other names and descriptions. The approach that the current project uses focuses on care coordination, as defined by the National Coalition on Care Coordination (N3C): “Care coordination” is a client-centered, assessment-based interdisciplinary approach to integrating health care and social support services in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an identified care coordinator following evidence-based standards of care.

Evidence during the past decade has found that a relatively small percent of patients account for a relatively large amount of cost and health care utilization. Demonstration projects among Medicare recipients have found that care coordination interventions can improve outcomes and reduce expenditures. Programs are more likely to achieve these results if they include the following components: targeting of populations with high utilization and need; in- person contact; connection with hospital and emergency room utilization data; close interaction between care coordinators and primary care physicians; and having RNs as care coordinators. The nurse navigator program  in La Plata County provides the opportunity to expand research findings related to the care coordination beyond the Medicare population and in a community-based rural setting.  If this program shows promising results, as expected, a subsequent larger scale trial of community-based nurse navigation in rural settings will follow.

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Lisa VanRaemdonck, M.P.H., M.S.W.

Emily Burns, M.D., M.S.P.H.