Hospitals use hands-on approach to reduce patient readmissions

(Post Tribune) Margaret Rondinelli, a 94-year-old congestive heart failure patient recently hospitalized at St. Mary Medical Center in Hobart, had a good friend accompany her throughout her hospitalization.

“She means a lot to me,” Rondinelli said of Gina Harris, of Dyer, an advanced-practice nurse and the chief navigator of St. Mary’s Quality Care Nurse Navigator Program. “She (Harris) is a very caring person. She gave me advice on how to do things and is always trying to help me. She’s made my stay in the hospital a lot easier.”

But it doesn’t stop there.

Last year Rondinelli fractured her hip and required surgery. Harris not only worked with Rondinelli and her family then to guide them through the process, but continued to check on her once she was discharged to her Chesterton home and later a nursing home.

“She called to see how I was doing and talked with my family about my condition,” Rondinelli said. “She was always interested and concerned about me, and you could tell that she cares.”

St. Mary’s nurse navigator program offers a glimpse into the future of health care, a way to improve the continuity of care not only during a hospitalization, but after discharge when problems often occur. The hospital assigns a three-person team that includes a nurse navigator, case manager and a social worker to monitor and track their patients’ care, sometimes even checking up on them months later.

The program offers patients and their families a single, familiar face they can count on for answers, questions and to assuage the fears and concerns patients have in what can be a huge and confusing institution. The goal is to improve the quality, not only of the patient experience, but of the care delivered. Many patients, especially those with chronic illnesses like Rondinelli, frequently visit hospital emergency rooms and are readmitted to hospitals, episodes that can often be prevented through patient education, diet and adherence to medications. The federal government is clamping down on unnecessary hospital readmissions and is penalizing hospitals financially if their readmission rates are too high.

So hospitals are struggling to reduce those rates. The nurse navigator program helped St. Mary cut readmission rates by 13 percent, hospital Chief Executive Officer Janice Ryba said.

Rondinelli’s daughter, Marge Tittle of Chesterton, said her mother met Harris four years ago when she had heart bypass surgery and remembered her when she broke her hip last year.

“Gina has been a godsend,” Tittle said. “It’s been truly helpful to our family. Many people see or treat my mother. But it’s nice to have one person with all the answers.”

She said several weeks ago her mother’s blood pressure dropped and she became unresponsive. The ambulance driver took Rondinelli to another hospital ER.

“Not having Gina was very frustrating. Often the nurse on duty was unaware of something that happened. We felt like there was a missing link. That was Gina.”

Tittle said Harris explains confusing medical terminology and answers family questions.

“We always know who to talk to,” she said. “She was like the glue that bonds everything together. It’s very comforting.”

Harris, a nurse since 1983, likened her job to a ship captain steering a vessel through troubled waters.

“The health care system can be just as treacherous,” said the cardiovascular clinical specialist. “But a nurse navigator knows how to guide the patient and family.”

Harris was the first in St. Mary’s pilot program. Now there are six advanced-practice nurse navigators with specialty training. Each averages about 30 patients at a time and meet daily with their teams to discuss their conditions and discharge plans and make rounds to visit patients.

“We’ve had some really difficult and challenging conversations about very big issues,” she said. “We collaborate with doctors, nurses and chaplains to find the answers, whatever the family needs.”

Nurse navigators have located free or discounted medications or equipment when patients can’t afford them and often connect patients to social services in the community.

“We’re there to keep the family informed, coordinate care and make sure things are going smoothly and efficiently,” Harris said. “Patients even call me at home on weekends. We’re the stable force throughout their stay and after.”