Nurse Navigators Chart The Course

According to the American Heart Association, approximately 5.3 million people in the United States have congestive heart failure (CHF). Over 1 million are hospitalized every year, and nearly half of those are readmitted within four to six months after discharge.

By Nancy Giguere, Star Tribune Sales and Marketing

Last update: October 26, 2009 - 10:19 AM

According to the American Heart Association, approximately 5.3 million people in the United States have congestive heart failure (CHF). Over 1 million are hospita- lized every year, and nearly half of those are readmitted within four to six months after discharge.

A Complex Disease

"CHF patients have to pay attention to their meds, their diet and fluid intake, their weight and their activity. It's a complex disease," says Juliet Mock, heart care clinical nurse specialist at St. Joseph's Hospital, a member of the HealthEast Care System.

As CHF nurse navigator, it's Mock's job to connect patients with the resources they need to remain as healthy as possible and avoid readmission to the hospital.

Getting To Know Patients

Mock reviews the medical records, test results and medications of all patients with CHF admitted to St. Joseph's. Then she visits them, answers questions and, if necessary, refers their concerns to the physician.

Sometimes Mock does a nursing assessment. "I try to learn not just about their physical conditions but also about their social circumstances. For example, how knowledgeable are they about CHF, can they afford the prescribed medications, what kind of social support do they have?"

Linking Patients To Resources

Mock works with an interdisciplinary team that includes a social worker, a transition coach who helps patients move smoothly from hospital to home and a clinical resource specialist who assists patients with financial and insurance issues. Depending on the situation, she may also link patients with dieticians, cardiac rehabilitation specialists, and home health, palliative care or hospice providers.

Nurse navigators have worked with cancer patients since the early 1990s. More recently, navigators have begun to coordinate spinal and bariatric care. Because CHF is on the rise, Mock believes that nurse navigators may one day be common in this area, as well.

Nancy Giguere is a freelance writer from St. Paul who has written about healthcare since 1995.

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