A care navigator (CN) team was developed starting in 2012 under the Michigan primary care transformation project consisting of 28 care navigators, working at 14 primary care practices utilizing the patient-centered medical home (PCMH) to improve patient health.
Our goal is to reduce hospitalizations, readmissions, and ED visits through the use of care navigators. The care navigators are embedded into each primary care practice.
Elements of the care navigator role
• Assessing the patient’s healthcare/psycho-social needs and those of their families
• Providing self-management support, care management, care coordination, medication reconciliation, nutrition, safety, and follow-up appointments
• Comprehensive individualized plan of care through use of evidence-based protocols and guidelines
• Coordinates with other members of health team, including PharmD, social work, nutrition, and community resources
• Assists with advanced directives, palliative care, hospice, and other end-of-life coordination
Though new care navigators are required to complete a self-management course, as well as a state-led case management course, there was a need for an improved onboarding/orientation program within Michigan Medicine.
A committee was formed with seasoned care navigators to design and implement an onboarding process that would fully prepare the new RN navigator for the role within their assigned clinic. The committee utilized the AAACN transition of care/care coordination guidelines as well as the Case Management Society of America standards as our golden rules. The onboarding consists of 6-8 weeks of clinical courses and rotations with a variety of care navigators. There is shadowing with inpatient case managers to understand their role and establish communication with the discharge planners. There is shadowing with our social work complex care managers who work with the neediest and most vulnerable of Michigan Medicine patients. This is invaluable for learning how to access community resources for our patients and for understanding the patient experience moving through Michigan Medicine System.
The committee developed an orientation manual for all the care navigators. This notebook contains an index with the important details needed to learn to function successfully once the care navigator is onboard in their unit. Each person involved in the orientation knows what to expect to review on the day they host the orientee. There is a checklist for each step, and the care navigator takes the notebook with them to each unit. This has resulted in the standardization of care navigator training, our workflow, and documentation. Following orientation, we assist with daily support by assigning a seasoned CN to touch base with the newly hired. All the care navigators have voiced appreciation for having a printed copy of the procedures we follow for transition of care, enrolling patients into case management, and copies of our documentation templates.
1) A post-orientation survey was sent out to the five care navigators who have completed the new onboarding process to assess the results. Feedback allows us to continue updating the program.
2) Impact on clinical metrics remains to be measured. These measures will reflect the impact of the whole team.