P28B

Onboarding Care Navigators at Michigan Medicine

Free
Standard Price

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.

Lessons learned
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.  

Speakers

Speaker Image for Janet  Pund
Janet Pund, BSN, RN, BC, CCM
Speaker Image for Deborah  Schmidtke
Deborah Schmidtke, BSN, RN, CCM

Related Products

Thumbnail for Developing a Population Health Infrastructure with RN Navigation and Care Management Foundation
Developing a Population Health Infrastructure with RN Navigation and Care Management Foundation
As healthcare organizations embark on the challenges of introducing the concept of population health in the ambulatory care setting and shifting to a value-based care system, there is a change in how patient populations are managed regarding their overall health and well-being…
Thumbnail for Development and Validation of a Medical Home Model for Persons with Spinal Cord Injuries
Development and Validation of a Medical Home Model for Persons with Spinal Cord Injuries
Background: Access to primary care is vital for any patient. For patients with disabilities, particularly with spinal cord injuries, primary care is difficult to find…
Thumbnail for Transitional Primary Care Clinic - Care Coordination across the Continuum
Transitional Primary Care Clinic - Care Coordination across the Continuum
Access to primary care services is a central component to a patient’s successful transition after a hospitalization or an emergency department (ED) visit…
Thumbnail for A Virtual Care Coordination Clinic for Children with Medical Complexities
A Virtual Care Coordination Clinic for Children with Medical Complexities
Nationwide 3 million children are classified as medically complex, which is defined as three or more diagnoses or conditions. While this pediatric population accounts for a small percentage of the overall patient population, they are the highest utilizers of medical services…
Privacy Policy Update: We value your privacy and want you to understand how your information is being used. To make sure you have current and accurate information about this sites privacy practices please visit the privacy center by clicking here.