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  Today on Town Hall

(INTRO)   You have your inpatient side of the world and that's a silo and then you have your outpatient side and no one communicates together. So we want to help be that bridge   📍 My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health.

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 Hi everyone, welcome to one more Townhall episode of This Week Help. My name is Karla Arzola and I'm the CIO of Rocky Mountain Human Services and I'm your host for today. We have with us Brooke Brown. She is nurse navigator at Magnolia Regional Center and we're just going to go ahead and do a quick intro.

Hi Brooke, how you doing? I'm good. Thank you for having me today. Yeah, absolutely. Thank you for being with us. We are anxious to hear about the program that you have put in place. But before we go there, let's start with, why don't you give us a little bit of an introduction? Who are you? What's your role?

And maybe you can tell us a little bit about the organization as well.

Okay, perfect. My name is Brooke Brown. I've been a nurse for 10 years. My main background is specializing in the surgical intensive care unit. I've done dialysis, home health, hospice, and then I've also worked on just a general med surg floor.

But for the last year and a half or so, I have been in the nurse navigator role, and also includes remote patient monitoring. So it's a complete 180 of what I work in. Was used to as a bedside nurse, but it's been a great transition to see how the other side of health care works. And then, of course, how they work together as well.

But that's a little bit about me. And then, as far as our organization, we're about a 200 bed hospital in a rural Mississippi. We're at the very tip top, close to Tennessee. So we have a catchment area of it spans across three different states. A great place to work. So it's been good.

That's awesome. Thank you for laying through. We appreciate that. It's always just good to learn, the background of the hospital, where you're coming from, your experience. And so let's get to the interesting piece about the conversation. So you championed a nurse navigation program.

focused on patients with congestive heart failure. Why don't you tell us about the program and what were the drivers? What prompted you to start this program?

The main drivers of this program was hospital readmissions. We always have that big quality piece of how can we help these patients and prevent them from readmitting to the hospital.

So when we looked through all of that quality data, we found that Congestive heart failure patients are one of our biggest contenders of have the highest rates of readmission. So that's where the population came from that we wanted to focus on. And then from that my work primarily focuses on identifying those patients that actually have congestive heart failure.

And then from there Because the concept of nurse navigation is not new, it's been around for a long time. And so we were like, how can we help these patients? And so what I do is, once the doctor says, hey, this patient has congestive heart failure, reduced ejection fraction, I will go with them and I will sit down and first just introduce myself.

Hey, my name is Brooke. And just try to start there with that rapport. And we talk about their home medicines, can they afford their medicines, any barriers to that, because I mean they may have a medication list a mile long, but they're not taking any of them, and then if they can't afford them, they're for sure not going to take them.

And we just meet together in the hospital. I give my contact information, I verify their information because the amount of numbers that are wrong, and then we It just, from the registration process, it just, I don't know how it happens, but I think everybody just says, yes, this is my phone number, and it never hardly is.

And then, so that's all I do when I meet with them, and I tell them, after you've been discharged, I will make my first phone call within 72 hours, and then from there, I will put all of their information down and , we use the Dr. FIRST PRM tool and I put their information in there and I call the patient, I review their medication list we talk about making sure the patient actually understands Why they were in the hospital in the first place.

Give 'em that knowledge and help just explain to them things to look for. Are you swollen? Are you taking your medicines? Did you pick your medications up from the pharmacy? Do you have a ride to your follow-up appointments, if they don't have those follow-up appointments made, I will make 'em for them.

Call 'em, give 'em dates and times. And then we also, if they text I'll text 'em as well. But mainly all just telephone calls. And just make sure their medication history is updated. And then I would just let them be the driver of how we proceed next. I typically call once a week for 30 days.

30 to 60 days is typically how long I will follow them. But if they're younger and they don't really need much, I may just follow back and check on them. Maybe three times instead of four, there is no right or wrong. You can never call too much kind of thing. And then if it's someone a little more needy, I might call them twice a week, especially in those first like 14 days.

But our biggest goal is to just be the care liaison for this patient. And because we see in healthcare, everything is so siloed. You have your inpatient side of the world and that's a silo and then you have your outpatient side and no one communicates together. So we want to help be that bridge of if I can meet you in the hospital and start building that rapport and they have a single point of contact, then be the hands and feet to the clinics as well.

And if they need a case manager, I can get in contact with that or be that person if it's needed.

And it's super important, right? Going back to basics and creating that relationship between the clinician and the patient. Because it's not just about the patient being in the hospital, then they get discharged.

And you're right. Most of the success relies on if the patient understands their condition, and are they going to be able to take care of themselves when they leave the hospital. So you're taking on that role, it's. Key, right? And I love that you've done that. How many, and just out of curiosity, how many patients do you have enrolled in your program right now?

Right now, we have 15 that are currently in the hospital. Now, overall, that's a bigger number. Typically it's about 50 that are on my list in a given month. And that's a rolling list, of course, but that's a good average.

And it being this summer, it's a little bit lower than what it typically is in the winter months.

This is great. And so you start with that relationship, you follow up with them. You make sure that they understand their condition, you make sure that they understand why are, they in this program,

walk me through, how do you believe this program empowers them? Because it's not just about going to take your medication, right? You do other things along the way. So can you walk us through that? What does it mean to be a patient?

It empowers the patient is by giving them knowledge.

We can help give them all the keys to success, to help them manage that. So we really focus in on education, of course, because with these patients, it's with heart failure, you have more than one medicine to fix a problem. Typically they have at least four medications and you have to convince them like I'm used to being my stomach hurts, I get one medicine for my stomach and my stomach feels better.

With heart failure, this isn't something that's just going to completely go away. You have to convince these people of you have four or five new prescriptions. Why do I need all four of those? Don't I just need one? So giving them that education piece that it takes all of these medications working together to help manage your heart.

disease process to prevent being in the hospital. And if we can do that helps your lifestyle, your quality of life, the longevity of your life, and your family's lives. So really just helping them understand because most people want to do what's right. It's just they lack sometimes the knowledge of what is right.

We help making sure they understand a diet because, we live in the South. So everything is fried, it's highly salted, it's processed helping them with the resources they need to make better choices. Because when you're in the hospital and you're so sick, you can start talking about Modification, lifestyle modifications, but typically, once you're in the hospital, you're so sick, you have to get them on all the medications, get them well, and then, from my side of the world, is when we can talk about lifestyle modifications. So that's just another part of the knowledge is power, and just building those meaningful relationships. Also empowers them because they feel like they're not doing it alone. They have somebody they can contact. It's not an answering service. And if they can call or text me and they know I'm going to call him back.

And if I don't have the answer, hopefully I know someone who does.

Absolutely. That relationship, that trust, extremely important because then they probably start opening up about. really what they eat and some of the challenges potentially they have at home. And you can find, like you mentioned, other resources to help them out through their journey versus just whatever it was capturing during the, the visit when they were at the hospital.

It's not alleviating that burden of disease, which, that's their biggest

challenge.

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Let's take a step back and talk about technology. We all understand that solving a problem it takes a few things. It takes obviously the caregivers, it takes the patients, it takes the care providers as well.

And but also the technology component can facilitate some of those things. Can you walk us through How are you leveraging technology right now to help this process?

Absolutely, I would love to talk about it. It's, like I said before, nurse navigation is not new.

It's been an idea that's been around for a very long time, but without technology, you're on the phone, you're calling pharmacies, doctor's offices, the patients, and trying to gather all of this data together, can take hours to do that, and it takes time away from the patient. We use the Dr.

First, the PRM model, and that gathers all of that data together. It's the insurance claim data, prescription abandonment data the data from the pharmacies of the prescribers because most of these patients have more than one prescriber. It would be very easy if they only had one, but you know, it's multiple prescribers, multiple pharmacies and so all of that data is gathered together in one place, and it's, I can see in real time when I log in to a patient what medicines they were prescribed, where they filled, what time they picked them up, how they paid for them.

It just, it takes so many hours away from me just being on the phone on hold with someone and I can use all of that to focus on the patient's well being and then, efficiency. The more patients I can call, the more patients I can help the better outcomes we'll have.

So we're talking about a true mad reconciliation process through technology.

You're able to see everything that happened historically. Also, you're able to see If what you have planned for them it's happening, just out of curiosity, do you remember how long would it take? What was the process of the timeframe that it took before you put this in place till now?

And just average. I

really don't because when I started into this role, we were already using this data, this piece of technology. But cause it takes me sometimes, especially like patients that were discharged over the weekend, just trying to figure out, did the person, not only is the patient doing what they're supposed to, but you know, did the physician do everything they were supposed to on their end as well?

Like going through that list, making follow up appointments. It takes hours on Monday to. Muddle through all of that. So I couldn't imagine not having the technology piece of it. I would say three or four hours just to gather all that data.

That's amazing. Talking about efficiency, right?

All the time in those four hours, so you can do. Let's touch on outcomes. You initially mentioned your driver was reduced hospital readmissions. That's probably one of them, but I'm sure there's many other ones. So let's talk about those outcomes. What are, some of the successes?

or all of the successes that you have seen since the program was put into place.

So we have monitored our, most of our success off of the four pillars of medications that GDMT that's recommended for patients with congestive heart failure. And with those, let me get the results right in front of me, which is beta blockers, your, ACE, ARBs, ARNIs, MRAs, and SGLT2 medications.

And so we have looked at the prescriptions and the fill rates of those. And so with that results right in front of me. We have seen an increased medication adherence across all four pillars of those medications and a significant increase in prescribing and adherence to the newest pillar of the GDMT, with the prescriptions we have seen, which is, represents what the provider would be doing, is a 26 percent increase. And then in a bill rate, which would represent the patients, it's 109. 72 percent increase, which is literally unheard of.

Those were better results than we ever could have imagined. And that was over, I think, seven months of data. Yeah, seven months of data and with 361 patients. Wow, yeah. So, we have new prescriptions and the fill rates and what we have seen that With every inpatient visits, the fill rate improves, and then having the follow up calls improves the fill rates, and combined with the inpatient visit and the phone call, dramatically improves both.

we knew that it would work, but we just didn't know that it was going to work that well. a decrease in some of the. the prescriptions for the beta blockers

but with those, even if it's what we didn't think would happen, I think it's more intentional because we are, like, say if someone can't tolerate a medication, I document that. And so it's better to be intentional with the prescribing than giving a patient a medication they can't tolerate just to check it on a box.

So we do believe that the longer that we studied. These medications, along with this patient population whatever results we get, they're intentional, and it's for the best of the patient. Congratulations.

That's extremely impressive, especially the fact that you are even seeing outcomes that were not part of the plan, which is even Especially that fast.

Yes. Um, what is the future of this patients? What's the path from here? I

mean, really, the sky's the limit. And those just early results are volumes to that. Of course, we're going to continue to study these patients and hopefully the plan is to get, the rest of our results, and to post those in a peer reviewed journal, but really just better outcomes for the patient.

And that's such a cliche answer, but for our congestive heart failure patients, if we can continue to be intentional with the way that we treat them, their quality of life, and their longevity, It truly is the limit for them. The quality of life greatly improves. And as far as for our hospital organization, we want to expand that, we don't want it to just be heart failure patients, which I mean, is near and dear because they'll be the first group that we've done this with, but no, we see this going for diabetic patients, for your COPD pneumonia, anything of

these disease processes that don't just go away, that people, if we can, help patients know how to treat them, know how to incorporate them into their life it doesn't have to be, a death sentence or, for them.

Brooke, when do you talk about this is a program right now and you obviously are going to try to expand this best practices and what you're doing with your patients, depending again, what problem you're trying to solve for those, and everybody's trying to Make sure that we get better outcomes and take care of our patients.

What would you say to those that are considering putting a program in place for navigations or advanced programs and what they're doing? What are some of those lessons learned, things that you would do, that you would consider, and some of the things that you'd be like and make sure that you pay attention to this because this didn't work.

Definitely incorporate the technology early. Our partnership with Dr.First, and I'm truly not just saying that, it has made all the difference in the amount of hours that we can focus on our patients and just their partnership is always very open and any problem we have, they're there to help make our lives as easy as possible on their end.

And so we appreciate them and hold them near to our hearts for sure. But as far as. Just the day to day stuff. It really takes everybody. It's, an open relationship with the inpatient world, with your providers that work, your hospitalist, your case managers, your IT. We couldn't do any of it without everybody together understanding what our goals are.

So just, Everybody being on the same page helps tremendously to drive this and to continue for it to grow. And so I feel like when we first started, we all wasn't on the same page. It was like, what's a nurse navigator? Now, what do you do? Who are you exactly? Because I'm pretty much a department of one.

So, it's just, it's me. And so now, just getting on everyone's radar. So if anybody doing this could Do that first. That would be ideal. It'd save you a lot of heartache in the future, but it truly does take. everybody on the team working together to make any department successful, but especially, something like this.

A lot that you said you're a department of one, but you're not. It's truly you were able to partner and engage people. You extended your team, and it's not necessarily people that are within your department, but are just And your partners, people that bringing other components, knowledge, and understanding what you're trying to accomplish is super important.

So I'm sure it is, your team is huge, from your internal stakeholders to your external partners, everybody that collaborated with you. that's great. And I feel like one of the key things that you mentioned is you really. Explaining, what we're trying to do and then just bring everybody to the table.

So Congratulations. Anything else you want to add for this interview? Anything else you want to say? A closing statement?

I don't think so. I just appreciate y'all's interest in what we're doing. I think that's been the most humbling thing just that what we're doing truly is making a difference because you get so focused on just the monotony of what you have to do every day.

So actually getting to, talk about it and be passionate about it and help anyone that wants to do this because, you're not going to regret it. Even if you start because someone tells you to do it from like a quality standpoint. It's gonna be tenfold. it's gonna have a great outcome.

Amazing. Congratulations again. I super enjoyed talking to you. And we looking forward to hear more of your successes. And thank you again for sharing the space with us. Thank you so much. I appreciate it.

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