Nurse Navigator Role and Responsibilities

(This session must be completed in order to unlock the remaining sessions)

Estimated time to complete: 12 minutes

Role Creation and Development 

• History of the Nurse Navigator
• Definition of Navigation and Types
• Nurse Navigators throughout History

Learning Outcomes:

1. Describe the history of nurse navigation and the different types and models used in health care

2. List fundamental competencies necessary for a Cardiac Nurse to perform Nurse Navigator role

Clinical Pearls

Nurse navigation dates back to the 1990’s when a program was launched to save lives from cancer by decreasing barriers to care

Common barriers experienced by patients include: lack of insurance, lack of information, lack of trust in the medical system

Estimated time to complete: 25 minutes

Learning Outcomes:

1. Identify professional organizations that can serve as resources to the Cardiac NN

2. Discuss educational opportunities that are available to the Cardiac NN

Clinical Pearls:

Nurse Navigators competencies outline the knowledge, skills, and expertise to effectively assist patients navigate the healthcare system

Assessing health and financial literacy and work with the patient within those limits is key to successfully coordinate care within the health system

Effective communication includes active listening, verbal and written skills

Educating and reinforcing prior education on understanding diagnosis, recognizing potential symptoms, and self-care strategies should be included in patient education tools

Nurse navigators should develop and/or participate in quality improvement projects as part of their professional role

Professional organizations that serve as resources to the Cardiac nurse navigation include AAHFN, HFSA, ACC, PCNA, AHA, HRS

Activity in this session:

Clinical Advancement Opportunities

- Theresa Heyborne RN, BSN, CHFN

Additional Resources for HF patients.

Estimated time to complete: 65 minutes

Modules in this Lesson:

• Management of Patients in a Community Setting
  • Speakers:
    • Kathleen Chestnut, BSN, BA, RN-BC
    • Pam Kirlin, BSN, RN, CHFN, CHC
    • Miranda Frost, MSN, RN, WCC

Learning Objectives:

1. Verbalize the role of home care nursing in the management of patients in the community

2. Describe what social determinants of health are and how they impact heart failure patients

3. Identify strategies for success in the management of patients in the community

Community Health Nurses use a Holistic approach to help patients. Their team may include RN, OT, PT, SW, SLP, Diabetes RNs, Dietitians, Telehealth, Hospitalization Preventative Calls

Social Determinants of Health include health literacy, transitions of care, financial barriers, food insecurities, transportation, mobility, lack of caregiver support, socioeconomic issues

Health literacy may be influenced by: ability to read/write, understand/apply math, ability to use technology, vision/hearing, language, mental health, cognition, education level

The majority of nurses underestimate the rates of low health literacy in the general public, as they make their assessment based on interactions rather than objective screening tools

Low Socioeconomic status (SES) patients are more likely to have a hospital readmission than those patients with higher SES

As patients become more fragile, demands to meet their needs increase - Caregiver burden & burnout in caring for chronically ill individual: Multiple MD appts, Hospitalizations/ER visits, financial difficulties, medication management

Strategies for success: Increased focus on patients in lower SES areas, focus on symptom management, dietary education/utilization of food bank, med management, remote monitoring, interprofessional home visits, community based palliative care NP

If you would like additional resources on how organizations have implemented projects to improve their programs, please click here.

Estimated time to complete: 70 minutes

Modules in this Lesson:

• The Role of Nurse Navigators in Preventing Readmission
  • Speaker:
    • Linda Wick, DNP, APRN-BC, CHFN

• Successful hospital discharge organization and planning from the Nurse Navigator perspective
  • Speaker
    
    • Lauren Unruh BSN, RN-BC, CHFN

• Reducing Hospital Readmissions Visiting Nurse Agency
  • Speaker:
    • Claudine Hagan DP

Learning Outcomes:

1. Identify the importance of role the nurse navigator has in the transition of care for a cardiac/heart failure patient

2. Describe the key components for cardiac/heart failure patient education that can help reduce readmission

3. Outline ways the nurse navigator role can impact the care of the cardiac/heart failure patient

• Outpatient follow up for the cardiac/heart failure patient should be made prior to hospital discharge and should include a follow up phone call within 3 days of discharge

• Patients with primary and secondary diagnosis of cardiac/heart failure should be considered for home care programs that contain evidence-based heart failure care

• The nurse navigator is a key team member who helps coordinate the cardiac/heart failure patient’s transition of care with clear communication being an essential skill

• Outpatient care for the cardiac/heart failure patient should include weight management as well as medication assessment and reconciliation

Additional Resources:

• Health System & Post-Acute Home Health Collab promotes successful transitions to the Home
  • Speaker
    • Angela Washenko

Estimated time to complete: 110 minutes

Modules in this Lesson:

• HRqOL Assessment tools in HF Review
  • Speaker:
    • Morgan Lewis BSN

• Critical Conversations: Shared Decision Making
  • Speaker:
    • Colleen K. Mcllvennan 

• Difficult Conversations across the Continuum
  • Speaker:
    • Emily Benton PhD 

• Motivating Patients: A How to Guide
  • Speaker:
    • Samueul Sears PhD

• Referrals to Psychosocial/Support Services/how to create a support group
  • Speaker:
    • Karen Weingart 

Learning Outcomes:

1. Understand the use of health-related quality of life (HRQoL) assessment tools in clinical practice and research

2. Verbalize how decision aid tools may be incorporated in the disease trajectory

3. Evaluate patient reasons for non-adherence and utilize techniques to promote patient motivation for self-care

The 2 most commonly HRQoL assessment tools used in Heart Failure include the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Minnesota Living with Heart Failure Questionnaire

Difficult discussions should occur early and often throughout the trajectory of a cardiac patient particularly when considering procedures (PPM/ICD/Ablations), medication changes (intolerance/cost), need for additional therapies (iHD) or adv therapies (LVAD/Transplant), symptom burden, caregiver needs (ability to drive), and/or quality of life.

Shared decision making involves clinicians working with patients to ensure that patient’s values, goals, and preferences guide informed decisions that are right for each individual patient

Decision aids should use plain language, avoid bias, and provide balanced information on risks and benefits. They should be used to complement rather than replace conversations with the healthcare team

Steps to motivate patients include developing shared goals and negotiating to make changes in small steps, while praising their achievements.

Support groups offer an opportunity for people to talk about personal experiences and feelings, and fills a gap between medical treatment and the need for emotional support

Estimated time to complete: 35 minutes

Modules in this Lesson:

• Basics of Healthcare Reimbursement and Nurse Navigator Role Documentation & Justification
  • Speaker: 
    • Leanne Schaller RN, CHFN

• Organizational Infrastructure of Outpatient Clinics and  Program Building & Staff Retention
  
  • Speaker:
    • Megan Mooney MSN

Learning Outcomes:

1. List 3 components of heart failure disease management

2. State 3 types of professional roles in a multidisciplinary outpatient heart failure clinic

3. Identify one CMS requirement to bill for transition of care services and/or one requirement for billing chronic care management

4. Apply the documentation and reporting information to justify a nurse navigator program/position or staff expansion

Clinical Pearls:

• Escalating health care costs due to heart failure and other chronic conditions coupled with the patient’s financial and emotional burden for managing their chronic condition are driving the need for nurse navigation

• A nurse navigator ensures the patient’s health and social needs are communicated and addressed across all provider and care settings

• Transition of Care and Chronic Care Management services are the cornerstone of nurse navigation leading to improved care outcomes and revenue for hospitals/practice groups

• Prepare to implement/expand nurse navigation services by planning for fixed/indirect/personnel costs and utilize quality/care metrics to justify the investment

• HFCs may utilize an interdisciplinary structure to deliver comprehensive care to the patients and their caregivers

• Disease management is a main component of comprehensive care and includes education and counseling, promotion of self-care, optimization of medical therapy, and assistance with social or financial barriers to health

• Continuing education and continuous quality improvement ensure the highest levels of knowledge and skill in providing competent heart failure care

Estimated time to complete: 45 minutes

Modules in this Lesson:

• Basic Research Principles, Nurses Role in Clinical Trials, Data Management and Informatics
  • Speaker:
    • Kelley Anderson RN, PhD, FNP, CHFN

• Putting the Fundamentals of Research into Practice
  • Speaker:
    • Nancy Albert PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FHFSA, FCCM, FAAN

Learning Outcomes:

1. Describe the nurse navigator’s role in research endeavors

2. Distinguish nursing research from evidence-based practice and quality improvement

3. Determine how to apply research findings into practice, utilizing principles of evidence-based practice

First step on a quality improvement project is to identify a problem or an opportunity for improvement

Select an improvement Framework i.e. Plan, Do, Study, Act

PLAN: Review literature for standards on care, recommended guidelines for disease management, strategies implemented in other areas that could be translated into the QI project and metrics that could be used to evaluate project’s success

DO: Create a team of experts that could collaborate in the project and develop a strategy to address the identified problem. Then, implement the intervention at small scale

STUDY: Observe and Measure success of the intervention. Determine what worked and what did not. Address issues that may be hindering success

ACT: Re-implement strategy with changes based on what was learned in prior stage. Disseminate knowledge or expand scope of the intervention if successful

Additional Resource:

• Research at the Bedside: How to Evaluate a Research Article
  • Speaker:
    • Marilyn Prasun PhD

Estimated time to complete: 40 minutes

Modules in this Lesson:

• Palliative Care for the Nurse Navigator
  • Ann Laramee NP

Learning Outcomes:

1. Identify signs and symptoms present during the EOL
2. Utilize assessment tools for symptom management during EOL

Clinical Pearls:

Diuretic resistance, HF medication intolerance and repeated hospitalizations may be indicative of end-stage heart failure

PC reduce symptom burden and improves HRQoL & decreases the cost of healthcare

Dyspnea, Fatigue and hypotension are the most common HF s/s at the EOL

GDMT may need to be deprescribed at the EOL to reduce HF symptoms

Early interventions at home reduces hospitalizations - Mobile applications provide PC education including emergency contacts, power of attorney, and symptoms that may be managed by PC services

Turning off ICD based on patient’s or families at the EOL is not illegal and is NOT considered physician assisted suicide

Timing of Device Therapy Discussion – make ICD therapy suspension part of the GOC discussion when hospice and comfort care are being considered

Estimated time to complete: 5 minutes

Please complete this overall evaluation to receive your CE credit and Completion Certificate.

Accreditation Statement

The American Association of Heart Failure Nurses (AAHFN) is accredited as a provider of nursing

continuing professional development by the American Nurses Credentialing Center's (ANCC)

Commission on Accreditation.

Learning Outcome(s) 

85% of all participants will self-report that by participating in this activity they are better able to self-report increased knowledge and confidence in managing the complexities of these cardiac disease states; effectively assisting patients to navigate the healthcare system; understand the nurse navigator role and how this impacts the care of the heart failure patient; the types of professional nursing roles in a multidisciplinary heart failure program.

Content Integrity Expectations

This educational activity must adhere to the following requirements:

- Educational materials that are part of accredited education (such as slides, abstracts, handouts,

evaluation mechanisms, or disclosure information) must not contain any marketing produced by

or for an ineligible company, including corporate or product logos, trade names, or product

group messages.

- All recommendations for patient care in accredited continuing education must be based on

current science, evidence, and clinical reasoning, while giving a fair and balanced view of

diagnostic and therapeutic options.

- All scientific research referred to, reported, or used in accredited education in support or

justification of a patient care recommendation must conform to the generally accepted

standards of experimental design, data collection, analysis, and interpretation.

- Evolving topics are presented without advocating for, or promoting, practices that are not, or

not yet, adequately based on current science, evidence, and clinical reasoning. Sessions that

cover these topics must be clearly identified in the program or agenda.

- Accredited education cannot include unscientific approaches to diagnosis or therapy, or

education that promotes recommendations, treatment, or manners of practicing healthcare

that are determined to have risks or dangers that outweigh the benefits or are known to be

ineffective in the treatment of patients.

- Faculty (speakers or authors) must not actively promote or sell products or services that serve

their professional or financial interests during accredited education.

- Only relevant relationships are disclosed to learners prior to the activity.

Contact Hours

Attendees may earn (up to) 6.5 contact hours by attending this activity and completing the

evaluation.

Claiming Contact Hours

Attendees can earn one nursing contact hour for every hour of educational time. Learners must

complete an evaluation to receive contact hours. The evaluation is available after the activity.

Disclosure of Relevant Financial Relationships

The individuals in control of content for this activity did not have any relevant relationships with ANCC-

defined ineligible companies to disclose, unless listed below. All relevant relationships were mitigated

prior to the start of the activity according to The Standards for Integrity and Independence in Accredited

Continuing Education.

Disclosure of Relevant Financial Relationships

The individuals in control of content for this activity did not have any relevant relationships with ANCC-defined ineligible companies to disclose, unless listed below. All relevant relationships were mitigated prior to the start of the activity according to The Standards for Integrity and Independence in Accredited Continuing Education.

Jen Fox, CRNP
Alnylam-speaker board
Johnson and Johnson - speaker board
Bristol Myers Scribb - speaker board
Merck - Speaker board

Rachel Barish, ANP-BC, AACC, CCK
Merck, CVS, United Health Group, and Johnson & Johnson: stock ownership
Astra Zeneca: honorarium for speaking

Nancy Albert, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN
Consultant to Merck and Lexicon
Research grant (through workplace) from AstraZeneca and Roche

Samuel Sears, PhD, ABPP
Medtronic and Abbott - consultant
Medtronic and Zoll Medical - speaker honorarium
Thryve, Tenaya, and Milestone Pharmaceuticals - quality of life expert

Disclosure of Commercial Support

AAHFN did not receive commercial support from the following.