This Week's Challenge: Using custom builds in its EPIC® EHR, Bon Secours Health System has developed sophisticated reporting, patient registries and a predictive model to identify high-risk patients. Their RN case managers, also known as nurse navigators, use tools like registries inside the EPIC platform. We wanted to identify the workflow for a nurse navigator.

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What We Learned: "Where does the nurse navigator spend their day? Certainly on transitions of care. They look at post-hospital discharges, emergency room visits, moving into hospice or palliative services, or even to short-stay skilled nursing facilities. If an individual identifies as having lack of resources then we’re going to look at a tool where those obstacles or barriers to care are identified, as well as a tool that can be used to connecting people to those resources that they need. When a person has multiple comorbid conditions, that’s a more complex patient who's going to require much more intensive management — if they have gaps in care, they’re not adherent to a plan of care, they have chronic pain, frequent visits to the emergency room, etc. That’s where the care coordination and nurse navigator’s activities are focused on."

— Robert Fortini, vice president and chief clinical officer at Bon Secours Health System.

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Excerpted from Improving Population Health Management Through Effective, Efficient Data Analytics, a 45-minute webinar, during which Robert Fortini drilled down on Bon Secours' tools and protocols for data analytics in improving population health management.

© 2013 Healthcare Performance Benchmarks by Healthcare Intelligence Network.
Editor: Jessica Fornarotto, [email protected];
Publisher: Melanie Matthews, [email protected]