Nurse-Driven Technology-Assisted Post-Hospital Patient Navigation in an Integrated Methadone Primary Care Setting

Learning objective: To discern the benefits and challenges of a multi-platform clinical decision support system and nurse driven workflow process to drive evidence-based practice.

Purpose and description: A novel informatics integration project to improve patient flow was the purpose of this quality improvement (QI) initiative. A new nurse-driven process was developed to address identification of high-need, high (acute) care (HNHU) patients’ emergency department/hospitalization (ED/H) utilization from disparate electronic platforms while facilitating remote triage (RT), in-person (IPT) nurse triage and patient navigation to care coordination. These software platforms include Microsoft Teams, CRISP Health Information Exchange, Methasoft, Epic, and Excel. For context, people with substance use disorders (PSUD) often represent a HNHU population requiring adaptive approaches to facilitate transition of care services. In a large, urban methadone clinic integrating primary care, a retrospective analysis found 23% of clinic patients were high emergency department (ED) users (4 or more ED visits per year) and 17% were extremely high ED (10 or more visits per year). High ED users had fewer onsite outpatient visits than non-high ED users: 1.44 versus 1.88.

Centers for Medicare and Medicaid Services incentivizes reducing unnecessary ED/HA to improve patient outcomes and reduce healthcare costs by increasing reimbursement for billable services. Literature indicates that there is evidence that patient navigation reduces ED visits and hospitalizations, and nurses prefer a standardized communication tool which reduces errors and is best done electronically. Evidence in the literature also supports a real-time locating system (RTLS) in healthcare settings is perceived by staff to reduce workload and increase productivity.

Preliminary outcomes/evaluation: Initial aims of engaging different staff units to communicate real-time alerts via an additional electronic Microsoft TEAMS channel was not deemed feasible in low-staffing environment undergoing construction. An adjusted workflow of systematic real-time tracking of ED/H across multiple e-notification platforms was more amenable to both patients and staff facilitating RT and IPT. This approach retained low-barrier methadone access for patients and allowed the staff to provide optimal patient experience. At the time of this writing, RT increased fivefold from week 1 (3) to week 8 (15), as did identification of rising ED/H by HNHU patients. This system allowed for the first-time integration of information from multiple software platforms to facilitate health assessment of ED/H patients while maintaining low-barrier methadone access.