Good afternoon, everyone, and welcome to the second webinar in our nurse navigator and coordinator series. We're so happy you're here. My name is Jenny Kennedy. I'm a VP with MedAxiom Care Transformation Team. Got some wonderful guests today. You're going to hear directly from them. We've got Emily Horner. She is the Structural Heart Coordinator at Tucson Medical Center. And then we also have Hannah Siporski and Holly Holtz-Claw, who is calling in until we can get her camera situated. If not, she'll still be able to join us. They're our heart failure nurse navigators from Wellstar Health System. So welcome, all, and thanks for joining. So we're going to get started in the interest of time because we've got a lot of great information to go through. These are our disclosures today. Just a quick little housekeeping rule. In the chat, you will find access to our presentations. If you want to ask questions, then please do. We encourage that. We are going to have some dedicated time at the end of the session where we want to engage with you guys and have you answer or ask questions, and we'll answer them. We ask you do that through the Q&A. So at any time during the session, you have a question, pop it in there, and we will go over it at the end as time allows. So just a quick recap on how we got here. We're really trying to dive into what our nurse navigators and coordinators, how their roles are, how we structure them, how we can really incorporate them into our care team. So this is coming off of the nurse navigator report, and we reviewed those findings last month. So I encourage you, if you did not have the chance to view that, please go ahead and access that. There's a lot of really helpful information in there. And just to kind of remind you guys, there's 75% of those sites that participated are looking for nurse navigators. They're either in the process of hiring or considering getting them. So we want to make sure we're setting these roles up for success. The reason we decided today to go over the structural and heart failure positions is those are the programs that are most frequently covered. So we're going to get some really detailed information about those two roles and those positions today. And as you learned, we see so much variation between what they're doing. Tends to be very clinical heavy or administrative heavy. So lots of different tasks, lots of variation. So today we want to give you the opportunity to hear directly from the experts who are impacting their communities. Please welcome Emily Horner, our structural and heart coordinator from Tucson Medical Center. Welcome, Emily. Thanks for joining us. Just let me know when you want the next slide and I'll be happy to move forward for you. Just trying to get my video to come back up. Well, hi, I'm Emily Horner. It's still morning here in Tucson, but it's hot. So it could feel like it was three o'clock in the afternoon. Next slide. Go ahead. I am the structural, I'm a structural heart coordinator here at TMC. I've been doing this for about three years now. I was originally on one of our cardiac units and I was kind of recruited by one of our interventional cardiologists. They had a spot up here in structural heart, and he had heard me talk to patients that had been through our program, had gotten valve replacements or repairs through us or LACs appendage closures. And he had seen me in action as taking care of those patients post procedure and thought I would do really well up here. And I've actually loved this program and what we're doing here. A few things about Tucson Medical Center that kind of make us a little different than a lot of other facilities is we are a independent community owned hospital. We are a health system now, which means we've acquired some other small community hospitals within Southern Arizona. But having a community owned hospital has provided with this incredible support system. We are actually internationally sought out for our structural heart and clinical research programs, which is kind of cool because we just think we're a little hospital here in Tucson. We have over 500 beds as a full hospital. We have cardiac intensive care, step down ICUs, two cardiac observation units. We even have an overnight express cardiac unit that's attached to our emergency room. Within structural heart ourselves, we have three private practice cardiologists. They are all three of them are implanters. All three of them do all of the devices within our program, but they are a private practice. So we work directly with their MAs and their NPs in their practice to get things going. TMC owns the structural heart program, which is why we work directly for TMC and report directly to TMC in conjunction with our doctors. We are the largest structural heart program here in Southern Arizona. We are recognized nationally and internationally for both our commercial and research programs. Next slide. Our volumes just this year so far, we've done over 150 TAVRs, 63 mitral tiers, that is across two devices, and we've done over 200 left atrial appendage closures with two devices, both Watchman and Amulet. We also do clinical trials for new TAVR devices and transcatheter mitral valve interventions, and we are getting into the trials for the tricuspid space. Next slide. Some of the things as a coordinator here, there are three of us. We are all three RNs with BSN education, and all three of us have prior cardiac experience. Those are not necessarily must-haves, but they are highly sought after for this position. We are in-person here at the hospital five days a week. We work eight-hour weeks. We are salaried, so it's a 40-hour work week. We can kind of split that up as we need to, which is nice. It does allow some flexibility. There are no weekends or holidays, but we all three do have hospital-issued cell phones that we kind of keep check on over the weekend. If we have Monday procedures going, it's not uncommon to get a text message over the weekend from that patient or their families with a quick question. If it needs the doctor's or the NP's interventions over the weekend, we do have direct access to them. We can call or text them. We fall under the cardiac service line, so our director is the cardiac imaging director. One of our doctors is listed as the structural heart director. We fall under TMC. TMC pays our salary. TMC owns the program. We do report to one of our interventional cardiologists. We split our program between the three of us. I primarily have done left atrial appendage closures. I actually just took over the mitral space. We have a new coordinator starting next week, and she's going to take over left atrial appendage closures. I will stay in the mitral space, and then our other coordinator does mostly the aortic sever volumes, but we all three know each other's programs. We all three get to go to each other's valve clinic coordinators with Edwards, with Abbott, with Watchman, and Boston Psy, which is nice because that provides that overlap for somebody to go on vacation or for an emergency. Like I said, with having independent cardiologists, we work directly with them, their nurse practitioners, both in the hospital and at the clinics. We work directly with their MAs. We also work directly with our CT surgery physicians and their staff for TAVR days. Obviously, we have anesthesiologists that work directly with our patients because they are also echocardiography certified, so that's important with your, especially with the mitral space. And our cath lab staff, we have a very busy program, and we do all of the scheduling for these procedures, including the research ones, so we need to know what the cath lab has, what resources the cath lab has, what resources we need to get for those procedure days. We make sure that all the NCD protocol requirements are met, including the research protocols, weekly presentations for our valve spaces for that multidisciplinary meeting to ensure that we are providing the proper patient care, and then reporting those back to the patients and getting them scheduled, all of the insurance Medicare authorizations. We do not do the authorizations themselves, but we provide the authorization department with all of the information that they need to get approval. We schedule all the imaging scans, pre and post for these patients that belong in the hospital, so any CTs that are necessary. We also follow up with the office for ECHOs or TEEs that need to be done, follow-up appointments we put in, we have direct access to those implanters if there's questions post-procedure, and we kind of serve as that link to the floor nurse. They know us, they know how to get ahold of us, they know that sometimes it's easier to get ahold of us, and we can call doctors directly rather than utilizing a page system. That's what we're here for. Then we do all the patient education, call them from the first day that they hit our program and follow them through, give them updates, let them know what any holdups are, or if there's a change in the patient status that could really impact this plan of care, we relay that back to our providers. And then all of that we report up to our hospital administration so they can see how big our program has already grown. In the last three years, it has probably doubled if not tripled in volume, what challenges come with that, and what our continued expected growth is. We also have a TMC physician liaison and our industry reps that we help with, and they help get out in the community to make this program even bigger. We do have an admin assistant, and I want to highlight her because of all the behind-the-scenes work that she does for us. She helps collect all of the documentation that's needed for an evaluation, so if somebody had a scan done at an outside facility that we don't have access to, she'll request that stuff. We also work directly with Q-Centrics for our registry data, and she helps keep that up to date for us. And then she also records all of our minutes for any meetings that we have to go to. So we function as a team, and we work as a team very well. And our hospital functions so well as a team, and the access that we have and the resources that we have really, really is important to the growth of our program. And I can't stress enough that getting your hospital on board with Structural Heart or even a heart failure clinic is so important. And I think that's it. Great. Thank you, Emily. I had a couple of questions I wanted to follow up, and I love the administrative assistant. I think that would be very helpful with a lot of those more administrative tasks that many coordinators and navigators are dealing with on top of the patient care and, you know, patient selection or weekly heart team meetings. Tell me, do you know what the requirements are? So how do you, do you know what kind of background or training that position would need? Or what kind of person would you look for to have in that? Like what would their skill sets be? So it kind of was created with a person in mind. And she had come, she had been an administrative assistant for a few executives within our facilities. She worked for hospice doing administrative duties for them, for the hospice director. And then I think they were leaving that program. She had started before I did. And our Structural Heart program had gotten big enough that we needed help. And so it was kind of created for her. And then she's moved on to bigger and better things outside of Structural Heart, too, within administration. So we've actually just hired somebody, a new administrative assistant who came from, worked her way up from, she was a behavioral health sitter, essentially. And then she was a patient care technician. And then she works in our staffing office. So for us, it was just important to have somebody who knew how to manage multiple tasks at one time. I think that was by far the biggest requirement that we wanted. There was no education requirement. But having the PCT background, which our original one had some background in patient care, allows for the knowledge when we're talking, what we're talking about. But the biggest thing was being able to manage multiple things at once. And so our newest administrative assistant coming from the staffing office, you can bet that by doing nursing staff, like nursing and care tech staffing all day long for the hospital is surely going to be able to transfer over to here. Perfect. Yeah, I imagine so. So what if, imagine if you did not have that administrative support, how much additional time do you think on you alone with the tasks that she's doing add to your day? I think we timed this one time and the registry data alone added an extra, I think, two hours per patient. So if we're looking at, I've done over 200, we've done over 200 left atrial appendage closure procedures this year. So I probably have 300 referrals because there's probably about 100 in there that haven't gone to procedure yet or declined. So that's 300 hours, 300 plus hours in addition to the evaluation stuff that I do manage because I'm in charge of making sure that they fit the criteria that they meet the Medicare guidelines. That's just gathering the 45 day imaging study post-procedure or the six month follow-ups so that they can be inputted into Epic so that our abstractors can find them. Great. And then she's supporting what, three others? Yeah. Well, she's supporting, there's three of us total. So she's supporting two others and all three programs have registry. The registry alone is a huge reason to have our administrative assistant. Now I know not every facility does the coordinators or navigators have to do their registry. There's some that are lucky enough to never have to see it. But on the front end, when we're looking for labs before we schedule a CT scan, it can be tedious to go back every day and check to see if this patient's got in their labs. And she takes care of that for us and she finds the referral notes and it's just really kind of a fact-finding mission that she goes on and it's great. Yeah. I think that's just, I really love that you shared that because I think that could be helpful at sites who are trying to work that balance of, do we need an extra coordinator or a navigator versus is there another support role that can take that workload off of you guys? So I appreciate that information. I did want to ask you, I have so many questions, so I'm not going to go overboard, but I did want to ask you, I think you guys are doing, I've seen your program firsthand and I think it's amazing. You guys are doing incredible work. It's incredible teamwork, not only in the hospital, but on the outpatient side, you guys are really integrated, which makes that culture and which results in improved outcomes for your patients, job satisfaction, all of that. But I want to ask you, what are your biggest pain points and challenges within the role? What are those things that just are like, gosh, I wish we could figure out a better way to do that? And I'm asking because I think we just are overwhelmed with the mass amount of responsibility that you guys have. And where are those biggest opportunities that if we're looking to really structure these roles, where are those opportunities? I think that as you've said, you've seen our program and the communication that we have is amazing. But with that, it is hard to have three independent doctors who sometimes don't see what everybody else is doing. And so there tends to be some tunnel vision, and that's true with all of them. Mine are not any more special than anybody else's in their tunnel vision. But having the ability to, and the confidence as a coordinator or a navigator to say to them, no, we can't do that today because Dr. S is doing his stuff today. You will do, like, no, we're not doing, we cannot do that today. Or when the cath lab has, we've had some challenges with staffing in the cath lab and that we've run into and being able to come up with solutions or reprioritizing, those can get frustrating. And I really think the hardest part is if you don't have the backing of one, your director, and knowing that when you speak and say, you know what, we need to do this today. How can I help you? How can we help you so we can get these patients through today? Or being able to tell your doctors, we can't, we cannot do this. I think that that could be a struggle for some in just in if you don't feel confident or you don't feel like you have that communication with your doctors or your administrative staff, it could really hinder it and you just feel like you just have to always do what everybody says even if they're all contradicting each other or everything's overlapping and it's all a giant mess. Yes and I can we can absolutely see that you know I think that's what a part of the importance of this role having the experience and the confidence. You guys I often call are the glue of you're you're or the wizard behind the curtain right you're making sure everything is happening there's so many moving circus leader you know exactly pick pick your acronym and so I think all of those apply and I think those are really valid points and I thank you for sharing them and that is something we're going to talk about next month is that leadership support to allow you guys to really work to the best of your ability. So Emily thank you so much for coming on today. We'll we'll have you back on towards the end of the session. Now I would love to introduce to you Hannah and Holly from Wellstar Health System in Georgia. They are heart failure nurse navigators at a large system and I'm going to let them take over and tell us about their program. Ladies. Hello Jenny hope you're doing well. I'm going to start. This is Holly. So we are with Wellstar Health System. We are a seven hospital system located throughout Georgia in a new partnership with Augusta Hospital. Our system does use coordinators and nurse navigators but there's not a huge relationship between who does what. So our coordinators have been around a little bit longer I feel than the nurse navigators. We there's no real hierarchy between who does what we do. Each role is completely independent. Our core heart failure group does come together to meet monthly. So we have the inpatient heart failure RNs which Hannah and I both are. We have some an outpatient heart failure nurse navigator at our heart failure clinic. We have advanced heart failure navigators at our advanced heart failure clinic. One of our hospitals has a cardiac RN navigator who shares heart failure and MI. And then our two newest roles in the system are the pulmonary hypertension navigator and we now have an autonomic clinic RN navigator throughout our system. Next slide. So kind of delving into the inpatient heart failure nurse navigator role requirements that our system has is a BSN or higher, a minimum of two plus years of acute care experience. Cardiology experience is preferred and certification is encouraged as well. The job description it is vague and really that's because each hospital site and each clinic you know wherever these heart failure navigators are going is different and the needs are different. So you know the three bullets below are kind of the core elements and at the heart of the role is really the patient. And I view the nurse navigator especially in the hospital setting is we're meeting these patients where they're at. Whether they're newly diagnosed, they've had heart failure for years or they're just learning that they've had heart failure for years. Really just picking patients up where they're at and helping guide them through their disease continuum. But working collaboratively with multidisciplinary teams both inpatient and outpatient telephone visits and serving as a resource for patients, providers, nursing staff, and other departments as well. For the actual job the position is salaried. It's Monday through Friday. It's eight hour shifts but the hours are flexible for start and stop time. There's no weekends, no holidays, and coverage varies on location but on the inpatient nurse navigator side there really isn't another person that picks up the slack when someone's out. So it's really important for the culture of the hospital setting to be independent with their heart failure knowledge and kind of be able to keep things running. On site is the main kind of requirement. Remote mix is encouraged. I do a one day at home remote day but Holly has all five days in person. There is the majority of the clinical duties and patients and being there for the providers but there is also a piece that's you know calling patients can be done at home and data collection and meeting powerpoints and things like that that can be taken care of away from the hospital setting. And each of our hospitals that has a heart failure inpatient nurse navigator it's one FTE. And it's kind of interesting to note that each hospital has you know different patient beds, different volume of patients, but right now it's just that that one heart failure inpatient nurse navigator for each hospital. Next slide please. The core responsibilities for the heart failure inpatient navigators, transition of care, we do a lot of serving as a liaison between patient, family, and the health care providers, coordinating care pretty much with everybody. We are a resource to the clinical team. We are a resource to the community. We host heart failure support groups, community engagement events. We help with the clinical practice guidelines at our locations, participate in performance improvement projects. As far as the administrative duties, chart abstraction, we can lead and participate in QI projects, data collection and review. We're leading and participating in heart failure meetings, doing staff education, hospital-based heart failure program growth and development. All of our locations participate in the American Heart Association get with the guidelines program. So we help manage the data for that. We do have cardiac data abstractors who assist with that also. Hospital-based heart failure program growth and development. We do disease-specific education with patients. So for heart failure devices, screening at depalting locations, we do a lot of cardiomeds and impulse dynamics devices. So helping identify and then educate these patients and then even get them pre-authorized for the procedures. We schedule follow-up appointments for our patients, do hospital telephone follow-up calls. Some locations do phone calls with high-risk patients only and some so-called when we try to do it with all our acute heart failure discharges. And then we do social needs assessments. A lot of our patients are documented as non-compliant, which I hate the word non-compliant. There's never, there's always a reason for the non-compliance. Sometimes it's the patient choice, but sometimes we need to dive deeper, do a medication assessment with the patient. Can they not afford their medications? Do they not understand the medications or they have any side effects? At Paulding, our veteran administration, we do pre-authorizations to get the patient seen at the outpatient clinic instead of having to drive an hour to get to a local VA office. And then at Hannah's location, she helps patients with transportation as well. And this is kind of a breakdown of the Paulding role. So Wellstar Paulding Medical Center, it's 112 bed hospital. We are rural. Paulding is the second fastest growing county in Georgia. So when I came into this role about a year and a half ago, there was no real structure for a heart failure navigator. So we started out by looking at our data. We've reviewed all our readmission data, did a deep dive with our patients who were coming back into the hospital for all cause and heart failure readmissions, looked at our get with the guidelines and metrics. And we kind of developed a plan based on our hospital needs. So a day for me is pretty much when I come in, identify the acute heart failure patients, request GDMT changes, documentation for the medications for the patients, request order sets, make sure they have their strict eyes and nose, daily weights ordered, and help with any patient outpatient referrals. We help with the device considerations. We can do the education for all of that. And then other cardiac clinical referrals. So we have a cardiomyopathy clinic and amyloid clinic here at Paulding. We'll refer out to the Cobb Heart Failure Clinic or even our Adance Heart Failure Clinic, because that's what the patients are needing. So for our patient education, we have a very big multidisciplinary team who participates in that. Our cardiac educators are from a cardiac rehab side. They do a lot of the basic education with the patients, go over our heart failure book, but then our dieticians, our transition to care pharmacists, sleep navigators, doctors, APPs, all educate the patient and document their education. So where I come in from this is I do a little bit more motivational interviewing, break down the situation a little bit more for the patient. So we'll review their echo and talk about ways for them to increase their ejection fraction, the device education, if it's indicated, outpatient goals for referrals for weight loss resources, support groups, follow-ups. Our patients see a lot of different types of cardiologists, so helping them understand why they need to see the different types of cardiologists and what the difference are. We have a huge palliative care presence here at Paulding Medical Center. We do inpatient and outpatient palliative care, but also home-based palliative care. It helps with a lot of our bed-bound patients. We reinforce the basics of the daily weights, eyes and nose, fluid prescriptions, schedule their follow-ups. For outpatient, sometimes we'll get called from our outpatient cardiology group to do patient education for the cardio MEMS devices and get all that set up and do the discharge phone calls after the patients leave. There are a lot of rolling duties that we try to mix in with all the daily duties. So here at Paulding, we have a multidisciplinary heart failure meeting every two months. So I lead that, get all the data together, do the deep dive, see if we can identify reasons for readmission. I participate in the heart failure PIC meeting, which is the process improvement committee. Also share government's system heart failure task force. The system heart failure task force is the meeting where all the nurse navigators come together and talk about what's going on at all of our hospitals. I provide education to staff, so daily huddles, shared governance, boot camps. We have a new care partner I and O class to get education out. I lead and plan our local heart failure support group. We do a lot of different roles with projects. And I put a few examples on here just to kind of show how we can have very little involvement or have to run the whole thing. So we do not have a heart failure clinic here at my location. So we have been working on getting outpatient diuretics for our patients at the infusion center to help prevent admissions to the hospital. So that is a big logistical undertaking, getting lab involved to get the ISTAP for patient labs, getting the nurses in the infusion center educated, working with all the teams for that. Dispensary of Hope is a program that provides free medications to patients who do not have insurance. So getting that started here at Calding. And then a lot of new opportunities. We actually go on to the community and learn about things going on. So the recent heart failure conference we had, learning about some subcutaneous, Lasix, Furosix, meeting with the rep, getting all the information, setting up lunch and learns, getting the whole workflow put together for that. Blood volume analysis is something we use at some of our hospitals, but it's a huge undertaking. It involves nuclear medicine, a lot of hands in the pot. So navigating that. Home health partnerships, working with a home health partner to do home diuretic policies for patients and also working with telemonitoring for patients. And then these heart health days that we're doing, managing all these things for that, the location, the advertising. So it can be anywhere from a little bit of involvement to planning and undertaking the whole project. So for Cobb Hospital, some background on Cobb. Cobb is a 387-bed unit hospital facility, really kind of a community care hospital. But we do see a wide circle of patients from Atlanta. There's a burn center here. So patients do end up coming from Alabama and out of state over here. The role of an inpatient heart failure nurse navigator, I think, is really important. In the role of an inpatient heart failure nurse navigator, I think they had had someone maybe for a little bit on the inpatient side before I had come, but there wasn't really anything solidified. And I really came at the right time. So at Wellstar Cobb, they had a plan for a multidisciplinary mobile heart failure team that would include a heart failure navigator, a transition of care pharmacist, and a designated heart failure APP. And we had a huge Kaizen event, which is a big process improvement event with all the disciplines with ED, respiratory therapy, dietitian, inpatient units, hospital medicine, cardiology, to really kind of hash out what our system at the community level needed. And we did a needs assessment of the community and really the plan to develop a heart failure clinic was in place and things just kind of grew from there. But kind of looking at the list broken down, patient education is a really big part of my day today. And it's shared with our cardiac educators and we have transition of care pharmacists here and our heart failure APP. And kind of the big thing with that is, you know, there's so many people seeing these patients, they see, you know, probably 10 people a day coming in the room, that if someone picks up on their conversation that, hey, this patient has transportation issues, this patient has food insecurity, you know, they'll call me, send me a perfect serve, and I can kind of come in and tailor our session based on what's already been gathered. And really, I focus, since there's so many patients on the new diagnosed patients, reduced EF patients, patients that have readmitted and those with known social barriers to get the biggest bang for buck since I can't see everyone all the time. Individualized plan of care is a big part of that, kind of like what I discussed earlier. You can tell patients to do ABC, but ABC might not work for them. So changing it to whatever cookbook ingredients to make them successful outside the hospital is kind of our goal. And a big focus here is giving patients a link for when they start to get into trouble outside the hospital. Everything's always good in the hospital, but I feel like as soon as they step foot outside, you know, med issues pop up, they start to have swelling, they start to feel dizzy. So I give them my cell phone so they can reach out and whatever comes up, you know, whether it's calling their PCP or the heart failure clinic or our pharmacist or, you know, whatever is needed to stabilize the situation. With transition of care, scheduling the seven-day follow-up appointments as Holly mentioned, and really it's based on that individual patient. So a lot of patients come in and they don't have a PCP. And while that's not necessarily heart failure related, they need someone to manage their diabetes too because their blood sugars are out of control and that's playing into their heart failure. So facilitating that, we have a center for best health within the system that provides structured care for weight loss support, a sleep navigator, sleep and heart failure. Sorry, my phone getting perfect serves as I talk. But sleep navigator, a lot of our patients have issues getting their CPAP. And so having a way to bridge that gap. Palliative care, we had a big initiative to facilitate earlier palliative care referrals and really kind of make the culture that palliative care is a standard of care. It's just an extra supportive layer and helping with the outpatient as well. Our heart failure home health program, WellStar has an awesome heart failure home health program and it's built into our order set. But sometimes, you know, care coordination might not do the assessment or a patient might not quite understand. And they say, oh, we don't need that. But after able to kind of clarify, can get that set up and setting up transportation. So we found here that a lot of our patients cannot get to their appointments. You know, we set them up and they have a family member that works weird hours and can't get them there. So we have to kind of tweak and base it off what they need or they literally can't get out of the bed. They're bed bound. So we have to do a video visit and try and collaborate with home health to draw labs so we can, you know, our providers over at the office or clinic can know what's going on, utilizing the Medicaid transportation and Humana and Aetna, you know, when their insurance has it. The administrative duties. So when I come in to start my day, I review our EMR system, heart failure list, and we have a heart failure report and kind of have a running Excel spreadsheet that I manage and we share with the heart failure team, but kind of take people off the list that have discharged and put people on surveillance of our heart failure order set usage with our provider follow up as needed. We have an advanced heart failure report that gets sent out to you to try and make sure no patients slip through the cracks. So if there's a patient on there that needs escalation of care, help facilitate that as well. Device patient identification. We are trying at Cobb to really get our devices off the ground. We've got some enthusiastic physicians now. So Cardiomem, CCM, we have an Aim Higher trial and assistance with the preauthorization process, which really just means printing and scanning a lot of paperwork. Surveillance and process improvement for our initiatives. We have Vizient as our data source and then any hospital specific needs. So kind of like Holly mentioned, projects vary on how much support is needed. Right now, you know, readmission, length of stay, GDMT compliance, and we're working on a meds to beds program at Cobb Hospital with a go live in August 1st. So really trying to come up with innovative ways to take care of our patients and get them what they need and kind of trial and error, see what sticks, what benefits, what works, what doesn't work and just keep going. And then as a clinical expert resource, We have a heart failure cardiac PIC meeting. So management of that and we as Holly mentioned, WellSTAR has a community support group. And right now it kind of rotates between three hospital sites, but Cobb is one of them. So I support the Cobb location. And we have interdisciplinary rounds on the inpatient setting. So on the heart failure destination unit, I'm there to help support relay information from our heart failure team, answer any questions from the provider and kind of just make sure everything's buttoned up before a patient gets discharged. And then just development and implementation of education for the hospital. So we had Care Partner Academy to help with daily weights and I's and O's for the physicians. We just had a in-service on GDMT compliance. And we come to their monthly meetings twice a year just to touch base, reaffirm what our values are, what we're trying to do, what we're noticing. And for nursing, we do shift huddles, staff meetings and our heart failure bootcamp. Next slide, please. So this slide, coordinator versus navigator at WellSTAR, we really don't have a hierarchy between coordinators or navigators. There's no, you know, coordinator that the navigators report to or navigators that reports their coordinator. Both manage programs and patients. So we kind of took a picture of what was surveyed by MedAxim and just kind of showed that really it's the same on both sides at WellSTAR. All right. And so this is a quick breakdown of some of the challenges. So hospital pay is less than competitors. Demands of supporting multiple programs are kind of the middleman in a lot of ways. Leadership expectations. Our hospital may need certain things and then the outpatient setting may need certain things. Heavy workloads with significant phone time. New subspecialties with accelerated growth. Cost and time to maintain clinical expertise. Super important. We are the people going out into the community and bringing the information back. Lack of communication from the system level. We are delegates without authority. Conflicting and inaccurate data. We're getting data from numerous resources. It doesn't always match up. How do we know which is right? Which is the one we use for certain goals. Having supportive leadership is very important in this role. It's very autonomous. You need that leadership to be able to stand behind you and know that you're doing what you're supposed to do. And then there's a lack of understanding of our role and responsibility even within the hospital sometimes. Sorry. There's a provider reaching out about a patient having a medication issue. The benefits of having an inpatient heart failure nurse navigator, I feel like it's hard to capture on one page what the benefits are. A lot of those benefits you see day to day, those little wins with a patient that stopped eating pickles or threw out their pickles or a patient that finally made it to their appointment after you've tried for months and months to get them physically here. But what we've seen kind of at the system level on each site that has an inpatient heart failure nurse navigator is that there's a huge reduction in heart failure readmissions. Patient outcomes are better. Mortality rates are decreased. Our GDMT data is better. When you look at the individual patient, their quality of life is improved and satisfaction as well. So a lot of these patients, when they enter the medical system, they're kind of lost and confused and on their own. And just having someone find them, meet them where they're at, and give them the bridge of care and kind of bridge the gap between the provider and everything else to keep everyone on the same page is very appreciated. A better utilization of community resources. I feel like, you know, the different navigators at our hospital system are now experts at kind of finding out what's available in their community and how to get them to their patients. So Meals on Wheels or transportation or the senior center providing free diapers for a patient that doesn't want to take their Lasix because they don't have diapers. Just all those various things that you might not think of, but patients need. And then our four hospitals that have inpatient heart failure nurse navigators, can't say if it's a coincidence or not, but they all have gold glass with our American Heart Association heart failure get with the guideline metrics. I think that really just shows external validation of the quality improvement of a first navigator. Next slide, please. Key takeaways, just kind of expressing that, you know, Hannah and I have the exact same job title at different locations and our roles do vary quite a bit based on our day-to-day. So it's a highly autonomous role. Good candidates for the position have to be highly motivated and engaged. Very diverse responsibilities and you're a liaison between multidisciplinary teams. So you have to be a good communicator and very proactive. Well, thank you both so much. That's a lot of work that you're undertaking. So hard to imagine where your patients and your outcomes, but most importantly, your patients would be without you in those roles. So I'm going to ask Emily, Hannah, and Holly to join us back on screen. We do have several questions and Ari is going to help us. We'll go in order. So we do have just under 15 minutes left. If we do not get to your questions, we will answer them and get back to you. Please go ahead and use the Q and A, the green side here on the right to submit any questions and we can get started. Okay. For the very first question, this is going to be for Emily specifically. Do you have hospital-based program clinics or do your cardiologists see their patients in their private practice clinics? We do not have a hospital-based valve clinic or heart failure clinic. In fact, in town, we don't have a heart failure clinic. Our doctors work within their independent practice to see their patients in clinic as far as treating their valve diseases. They rely on that communication with their primary cardiologist and they go back and forth. That does present challenges because we would love to have a heart failure clinic or a valve clinic that patients could go to to assess their GDMT, especially for those mitral space and make sure that their medications are right. Not saying that primary cardiologists aren't doing that, but just to have that dedicated expert in that field would be great. So no, we do not utilize a valve clinic. No, we see our patients when they come in for procedures or when they come in for imaging studies. Thank you. Next one, I believe, is for you as well. We use Q-centrics as well for TBT registry and we have come across issues where the abstractors miss the KCCQs and five-meter walk documentation. How does your team document this information consistently so the abstractors know exactly where to look? We use the KCC printout form. And on prior to procedure, it's given to the patients to fill out and then it is scanned into the media tab for that patient. And so we've worked really hard with our Q-centric abstractors to find that in the media tab. And then a 30-day is sent out to the patients with a stamped, self-addressed stamped envelope for them to return it back to us. And that also gets scanned in and labeled. And all of it is attached to the procedure event for the patient. But they all live in our epic media. And like I said, we worked really hard with our Q-centrics to streamline how they can find it. Holly and Hannah, how do you cover the inpatient heart failure navigator work if the navigator goes on vacation or is on leave? We don't have any backup. So we have to really promote a heart failure culture here that doesn't require that. We want our nurses to identify their heart failure patients and know what they have to do. And then if there is ever a need with devices or anything like that while we're out, it pretty much waits until we get back. We don't have coverage currently at the polling location. And the same is at Cobb. I will say I have a work computer at home and my cell phone. Everyone's got my number. So people might message about certain things. And I can access the schedules to put people on if someone needs something. But there really isn't a second person that assumes the responsibilities when I'm not out or when I'm not there. I wondered how you guys, I think that's something that a lot of these positions struggle with, is what's that balance of education that you're responsible for versus the rest of the care team, including those bedside nurses? Because obviously you're not only an educator. We saw everything you do. How did you help create that culture of shared education? Just by talking about the importance with everybody, showing them our metrics, our data abstractors create a little flow chart. They pull 30 patients at random and grade us. And we don't like seeing the red. So we would take it to our meetings, take it to our rounds on the floor and just kind of let the doctors know, the APPs know we're all doing this education. We just have to document that we're doing the education. So the only part that's being added is the two minutes it takes to go make a few clicks in our EPIC system and document it. A lot of our physicians added it to smart sets and to templates so that they can go in and have a little blank spot and just put how many number of minutes of education they did. But it did take a while. This wasn't a short undertaking, but just kind of reinforcing it over time. And very similar to Holly, just empowering each person and what their role is and really highlighting that you do this already. You come in the room, you give them their water pill. You know, how can we kind of dig deeper and talk more about that to the patient and meet their specific heart failure education needs? But we've looped in dietician. So they'll put their minutes in because they're in the room usually at least for 15 minutes with these patients. Sometimes it's not more. The providers, APPs, just really trying to get everyone on the same team and that we're all here to meet this metric. And it's here for a reason. It's not like this was just made up to make our lives hard. Sometimes people might feel like that. It's really for the patient. And usually when everyone's documenting as they should, the minutes are way above an hour, you know, because the time we spend with our patients is huge. Sure. Great. Thanks for sharing that. Right. A follow-up as well. Who or what department does your inpatient heart failure navigator report to you within your hospital? So at Pauling, it's the director of our cath lab and EP services. And at Cobb Hospital, it's kind of a fusion. I have a direct manager. That's the heart failure clinic manager. And then I also report to our cath lab director at the hospital. Great. And I think you both touched on this a little bit, but with one FTE per facility, can you speak to the variation in volume across sites? Does the team shift work across geography based on this, or is each teammate's work tailored to their facility? I would say tailored to our facility. At Pauling, we see anywhere from 25 to 35 acute heart failure patients a week. I mean, sorry, a month. So a lot of that is just having to identify the patients who have the biggest need. And then sometimes when our census is lower, we can see more patients. But yeah, it just depends from location to location. The question kind of asking if it's spread out through, like, you know, reaching out to Pauling to help with a caseload or another navigator, there really isn't that crossing geography. But it really is more so tailored to that individual hospital site, and each FTE manages their specific hospital. Great. Thank you. How do you navigate the work of the heart failure inpatient navigator versus case management slash social work without duplicating efforts? It's all just about communication. We just kind of follow along behind them. And I try to see more of my patients towards discharge to see what we missed or what we could have done a little bit better. And so when I go see the patients, I go over everything with them and ask them, have we given you this coupon for this medication and also check their charting just to see if they have. I kind of consider myself at Pauling more of the ancillary to go in and fill the gaps from where there might have just been a little lack and need a little bit more. So at Cobb, I feel like in the hospital setting, our case management is very much focused on kind of emergency level type things, you know, very big picture, not actual transportation or even the coupons for the medication. So I feel like the care coordination at the hospital level touches the surface and then the navigator kind of digs deeper and bridges the gap to get whatever is needed to the patient. So, you know, they might put in the actual home health referral, but then we're calling home health to set up lab orders at home, or we're calling home health to say, hey, this patient needs extra support with their pill boxes. Can you please support this for this patient? Because they're blind. So just kind of going a little bit deeper. Well, thank you for that. And I think I'm going to start wrapping this up just for the sake of time. And I had one question that I wanted to ask all of you. We saw how many different tasks you're doing and everything you're managing. And that's one of the hard parts of how do we figure out what to do with these roles? And especially if it's a new program. I think you all alluded to the fact that kind of figure it out. So knowing that, what would you say to a site that has maybe got a navigator or coordinator that they feel could be directed? Maybe they're trying to figure it out. Or a new role that's starting, where would you recommend prioritizing your time and your energy to start with? For the structural heart side, it would really be learning the NCD requirements for the device. Because that's going to direct you on how these patients need to be presented. And the flow of care for these patients, especially valve diseases. And even with appendage closures, there are very black and white requirements. And if they don't meet them, there's not gray that you can still get them a Watchman device. And so that knowing and trusting your ability to tell a doctor, they don't fit the requirements as written. So how can we do that? I think that's the best place to start for structural heart is really understanding. And then make friends with your industry reps, because they offer all kinds of valve coordinator clinics, where you can go and learn everything. And even if you're I went to one when I was a week old coordinator. And, and I think those are so good, because you can learn from so many others on what works in their system and what's not working. And excellent. I think those are great points. We've got to tap into resources and networks and know that we're all of us are facing a lot of those same struggles. So within this community, we can leverage those relationships and working with our industry partners. Absolutely. Hannah, Holly, any last thoughts? For a new nurse navigator, I would really kind of recommend since the role so relational, I'm just kind of immersing yourself in everything at your hospital or at your specific site, you know, the physicians, the cardiologists, you know, making sure to meet them in the outpatient setting to, you know, people need to know what we're here for what you're doing to get that buy in to be successful with whatever initiatives your hospital's working on. It's really just taking the time and not coming in like a big steamroll. But, you know, Jenny taught me this, but going, you kind of go side by side and around and you just kind of work your way in. So everyone's on the same page and on the same team. Oh, sorry, Holly, go ahead. I completely agree. The only other thing I would add is get to know your community and your community resources. So you can get those to the patients. Absolutely. And I know we did get to get a lot of questions we did not get to. And I assure you, we will get back to you via email if you give us just a few days. And I just want to thank each of you for taking time out of your busy, busy schedules. And we heard a lot of great things. You know, we heard the communication between the inpatient outpatient teams, knowing your communities, the leadership support, all of these are critical. But we still have a lot of work to do. So we know there's still not a difference, a really clear differentiator between coordinator navigators. Where do they focus? You can see within both of those programs, the vast amount of work. So we're going to continue this work. I do hope this was helpful to you. We will continue the series next month with some CV service line administrators who will talk us through the case and how they're supporting and leveraging their navigators and coordinators within their programs. Please also use the q&a or the survey to tell us what you want to learn. I would love to continue this work and give you information that's helpful and beneficial. Thank you so much for your time today. If you do have any questions, comments or ideas, please don't hesitate to reach out to me personally. Thanks for your time.

nurse navigators

coordinators

roles and responsibilities

challenges and benefits

collaboration

patient education

patient outcomes

leadership support

multidisciplinary teams

hospital setting