Implementation of a Nurse Navigator Program in a Large Veterans Affairs Health System

Emeott AA, Holtz B, Moorish W, Davis JA, Krein SL. Implementation of a Nurse Navigator Program in a Large Veterans Affairs Health System. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 10; San Diego, CA.

Abstract for AcademyHealth Theme: complex chronic conditions (innovative methods for improving outcomes in patients with chronic complex conditions) Title: Linking Patients with Complex Diabetes to Self-Care Programs Authors: Ann Annis Emeott, Bree Holtz, Wendy Morrish, Jenny Davis, Sarah Krein Research objective: Research has demonstrated that patients with chronic conditions can improve their health through participation in self-care programs. However, getting patients who are likely to benefit to enroll in these programs can be challenging. The purpose of this study is to identify key patient factors that promote or impede efforts by nurses in connecting patients with complex diabetes to appropriate health services. Study design: This is a retrospective analysis of data collected as part of a computer-based, nurse-led intervention (called the Navigator program) delivered within a large VA primary care clinic. Population studied: Patients were identified via a population-based registry as having diabetes and meeting criteria for being at high-risk for complications, and were referred to the Navigator program. This study includes patients with an assessment completed by the Navigator nurse between December 2010 and January 2013. Principal findings: The majority of patients were male (97%), with an average age of 65 years. Among 397 patients with a completed initial assessment, 68% were referred by the nurse to a variety of VA programs or services. In total, 270 patients generated 501 referrals. Approximately 37% of referrals were for self-care programs, such as in-person and telephonic exercise intervention programs, home telehealth, and a care management program involving patients' informal caregivers. However, almost one-fifth (19%) of patients declined to accept any referrals. A higher percentage of patients who declined all referrals reported that they understood their health condition (100% vs. 91%, p = .04), were not interested in working on their health condition (73% vs. 46%, p < .01), and were not interested in traveling for programs (77% vs. 61%, p = .01), as compared to those who did not decline referral. Additionally, those declining referrals had higher mean confidence levels for completing health tasks (9.2 vs 8.6, p = .03), and managing their health (9.0 vs 8.4, p = .02). Compared to patients who declined all referrals, patients who did not decline had a higher mean number of primary care visits in the previous year (5.01 vs. 4.16, p = .02), higher mean pain scores reported for the week prior to the assessment (4.7 vs. 3.4, p < .01), and higher mean pain scores representing the highest level of pain experienced in the previous four weeks (5.5 vs. 4.2, p < .01). There were no differences in reported general health and self-efficacy in managing their condition between the two groups. Conclusions: Among our study population of high-risk diabetic patients, a willingness to work on their health condition and travel for services, knowledge of their health condition, confidence in managing their health, pain level, and previous primary care visits seem to predict patients' receptivity to accepting referrals to health services and self-care programs. Implications for Policy and Practice: Understanding what factors influence patients' decisions to consider and participate in self-care programs has important implications for program design and the development of effective strategies to encourage the use of these programs. This information can also inform outreach efforts by care providers and program staff to identify and engage patients who are likely to benefit from these self-care activities.