1. Nurse Navigators Lead to Cost Savings
Jane Russell, MSN, RN, Director of Continuum of Care
Good Samaritan | Vincennes, Indiana

2. Indiana’s First County Hospital
Opened in February 1908 with 25 beds
232- Bed Acute Care Hospital
Service area includes 9 rural Indiana counties and 4 rural Illinois counties

3. Frequent Flyers
Great if you are in the airline industry. Not so good if you are in the ED.

4. Top two reasons our patients over utilized our ED: Primary care
Frequent Flyers
Top two reasons our patients over utilized our ED:
Primary care
To attain medication

5. Our Frequent Flyer
Greg

6. The Model Assertive Community Treatment (ACT) Model
Safety Net Medical Home Initiative
National Committee for Quality Assurance (NCQA) Model

7. Benefits Nurse is available 27/7 when issues arise
Shorter waiting times for urgent needs
Nurse is available 27/7 when issues arise
Open five days a week with late hours on Monday, Wednesday and Thursday

8. Criteria for admission
Six ED visits in six months Or Two inpatient admissions in six months And No provider No insurance

9. How Does It Work?
The patient is seen by a Nurse Practitioner (NP) and may then be referred to a Nurse Navigator for care coordination services.
Patients who do not receive a navigation referral are monitored at every visit to determine any change in status.
The nurse navigator completes a thorough assessment in the patient’s home (so the patient’s environment and social situation can be assessed) and brings it back to the PCMH team.
The patient’s assessment is reviewed at the morning clinic meeting or huddle.
The entire team reviews the assessment and makes changes to the treatment plan as needed.

10. How Does It Work? (continued)
The patient is followed by the NP, RN, and CM and his/her care is communicated in the daily huddles.
For patients who have no money to pay for medications, the Good Samaritan Pharmacy has developed a formulary that can be used by the PCMH at hospital cost which ensures patients are able to acquire medication as prescribed.
Case Managers utilize community resources to help with food, housing and transportation.
A nurse is available to PCMH patients 24 hours a day, seven days a week which helps build a relationship with the staff and decreases visits to the ER.

11. Nurse Navigators
Advocate for and assist the patients in navigating the health care system
Provide care coordination
Provide health literacy education
Obtain medication and medical supplies
Provide nutritional counseling

12. Case Manager Provide Self-Managing Skill Development
Provide Education on Budgeting
Assist with Benefits and Resources
Teach Problem Solving Skills
Assist with Social Needs (Food, Housing, Employment, etc.)

13. Team Approach
The Daily Huddle occurs every morning before the clinic opens.
The first part of the huddle focuses on patients to be seen that day or patients who are in need of assistance that day.
The second part of the huddle reviews patients discussed the previous day, reports from the office visit or any other patient contact that was made.

14. Results

15. Financial
In the third quarter 2015, ER visits for PCMH patients were reduced by an average of 39 per month.
Inpatient admissions were reduced by 11 a month.
Using an average ER charge of $2,082.86, and an average inpatient charge of $9, the Medical Home cost avoidance is now $974,778 for the year.
The cost avoidance saved in the ER more than covers the cost of running and staffing the medical home.

16. Patient Satisfaction
93% of patients surveyed in Q4 of 2015 rated the care they received in the PCMH as very good and felt the staff worked very well together to provide very good care.
96% reported the likelihood of recommending the clinic to someone else as very high.

17. Questions?

18. Refrences
(accessed December 30, 2014)
Berwick, D., Nolan, T, & Whittington, J. “The Triple Aim: Care, Health, and Cost. Health Affairs 27, No. 3 (2014):
centered. (Accessed December 29, 2014)
Carver, M. C., Jessie, A., (May 31, 2011) "Patient-Centered Care in a Medical Home" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 4.
(accessed December 15, 2014)

19. Jane Russell, MSN, RN, Director of Continuum of Care | jrussell@gshvin
Jane Russell, MSN, RN, Director of Continuum of Care |