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Care Management Program Update

11-02-17Tonya Kirchmyer

The Signature Partners Nurse Navigator program provides high risk patients with additional assistance managing their health and living with a chronic disease. The Nurse Navigators work closely with the primary care physician and the patient to apply interventions and education to support the patient. Our Nurse Navigators create care plans after a face to face or telephonic assessment. The care plans will help the patients keep their wellness screenings current, chronic disease under control, reduce barriers to care, and enjoy a better quality of life. Nurse Navigators are assigned to provider offices by demographic area and priority high risk attribution.

Nurse Navigators can provide additional education and support to patients to help them manage chronic diseases such as Diabetes, CHF, COPD, and CAD. They can also assist patients with complex medical needs by connecting them to community resources and helping them navigate their care. Motivational interviewing techniques and teaching are key components of the program that help ensure the patients understand their disease process and how to self-manage their health.

Here are some of the ways we can help with your patients:

  • Navigate health care
  • Provide educational information
  • Support with managing chronic disease to facilitate self-management
  • Refer to Inova resources and community programs to support patients needs
  • Assist with setting up appointments to facilitate care
  • Follow up on referrals
  • Assist with continuity of care
  • Assist patients with personal barriers to care and self-management

Innovation Nurse Concierge Program – Licensed practical nurses and Registered nurses outreach Innovation Health patients who are at risk for further utilization or deterioration of health status based on claims and diagnosis. A telephonic outreach is placed to the patient to screen for needs in managing their health, assistance with coordination, and referrals to the high risk program with Nurse Navigator support if needed. Patients with multiple ED visits in 6 months are screened for access concerns, educational on site of care deficit, or other needs to manage their health to reduce ED visits.

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