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P43B - 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. Care coordination has become more important in the outpatient care delivery environment, and RN navigators can assist primary care providers in handling tasks that have often in the past been the responsibility of the provider. Incorporating some key aspects of the patient-centered medical home, care coordination can free up the provider to manage the medical care of the patient, while other barriers are addressed through RN navigator interventions.

To address the population health needs for primary care organizations, skilled RNs are needed to focus on patient care topics such as prevention and wellness, determining gaps in care, addressing social determinants of health, as well as evaluating clinical data for improved patient outcomes. Implementing the role of a RN navigator helps extend the reach of the care team. The RN navigator in the outpatient care setting collaborates with the patient and family, primary care providers and other clinical staff, social workers, dieticians, inpatient care team members, as well as other community agency stakeholders who contribute to the patient’s care team to ensure patient needs are addressed for meeting care goals. The goal is to provide integrated patient-centered care that can intervene early to avoid chronic illness and for those patients that have chronic illnesses, provide education and help guide in the development of self-management goal setting to avoid further decline in health status.

Development of the RN navigator position was initiated to engage with the ambulatory care team to manage patient populations and to optimize health outcomes. The data management team using a health analytics platform program cued specific clinical triggers to identify and stratify patients for cardiovascular disease, chronic obstructive pulmonary disease, and palliative care needs. Daily schedules for the RN navigators are generated from this target population to develop a daily plan to see patients. Guided by motivational interviewing, the RN navigators meet with patients to help them identify self-management goals, such as smoking cessation or weight loss, to drive outcomes. Collaboration among care team members can enhance positive health outcomes for the population served. Sharing best practice recommendations can assist others on this journey of developing effective population health management of chronic illness.

The RN navigator role is a vital component to working with patients who have challenges and barriers to maintaining optimum health with chronic disease and providing assistance in navigating the complexities of the health care system to ensure needs are addressed that can aid in positively impacting their overall health and well-being. Collaboration among care team members can enhance positive health outcomes for the population served, and RN navigators have the important role of coordinating the care team members in the ambulatory care setting.  




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