It’s no surprise that the landscape of healthcare is ever-changing. That’s the way it has always been from technology and services to changes in staffing, workload and expectations. Time and time again, our stellar healthcare facilities rise to the challenge – the newest challenge being a shortage of providers in healthcare across the nation. The shortage runs the gamut from physicians and technicians to surgical staff, bedside nurses and all the medical practitioners  in between.

To continue providing quality care in the midst of this scarcity, we’re asking nurses to serve in more of a primary care role, but it’s so much bigger than that. The beauty of expanding the role of nurses is that it gives them autonomy to practice up to their license. 

Creating an environment for full license usage, we invite the professional registered nurse into an opportunity to lean in to patient care and their roles on the care team. For those who want it, it can offer a sense of independence. Plus, these are the people who are amazingly good at coordinating care.

At HSHS St. Joseph’s Hospital, like many hospitals, doctors making their rounds have limited time with each patient, but nurses are with patients every hour of their stay. Nurses know what’s happening with each patient at all times and they receive anecdotal feedback. The nurse understands the condition of the patient in ways that go beyond just their physical needs over a length of time.

Another idea that’s not necessarily new, but that is gaining is the nurse navigator. Nurses in these roles are a combination of appointment coordinators, nurse educators and health coaches. They become involved with the patient even before admittance and are a resource for the patient through discharge and beyond. We have a great template from our colleagues in oncology – the leader in the creation of healthcare navigators. 

Nurse Navigators

Harold Freeman, M.D., initiated the first patient navigation program in 1990 at a public hospital in Harlem, N.Y. His program focused on eliminating barriers to timely care between cancer diagnosis and treatment. Now more areas of healthcare are adding these specialized nurses. 

As an industry, we should be proactive in applying this model to all disciplines. Already in many hospitals, cardiology patients are reaping the benefits of nurse navigators. People suffering from chronic diseases such as chronic obstructive pulmonary disease are helped immensely by the coordination supplied by navigators. 

Home health and hospice nurses often act as nurse navigators – the medical liaison for patients and their doctors, as well as making sure patients’ medications and treatments are provided in a correct and timely manner.

Nurses in homes use a variety of technology from lab monitoring devices to specialized wound treatments, intravenous therapy or telemedicine. They are the eyes and ears for medical providers. These nurses have the greatest opportunity to achieve success by engaging patients in managing their healthcare needs in the daily settings in which they live.

Hospice to Home

HSHS St. Joseph’s Hospital’s Home Health and Hospice program, also offered at HSHS Sacred Heart Hospital, has taken a nurse navigator approach to patients who are ready for discharge. Aside from the traditional home health or hospice role, the service has implemented the Hospital to Home program. Discharged patients are provided with a 30-day post hospital discharge follow-up. Nurses make home visits and phone calls if a patient does not qualify for traditional home health or hospice care. 

As hospitals, we are always striving for top quality of care and efficient transitions of care. We’re constantly working to reduce rehospitalizations. Although hospitals face a penalty when patients are readmitted within 30 days of discharge, our primary motivation is that we want to give the best, most thorough care possible in the environment that is appropriate. 

We believe this commitment and patient-centered focus will help us to achieve greater community well-being. The program was launched in July 2014. Although the service is not reimbursed, we quickly learned that the benefits of the program for the patient and the hospital outweighed any additional cost incurred. 

We saw case management and discharge planners become more confident in their roles because they felt a greater opportunity to refer patients. They didn’t have to guess whether a patient would qualify for services because reimbursement was not an issue in the decision matrix. They just focused on patients and their needs.

In the same way, case managers and discharge planners didn’t need to determine if a patient qualified for traditional home care – they could simply decide if a patient would benefit from follow-up care and make the referral. Once the referral is made, Home Health colleagues determine if the patient qualifies for more ongoing traditional care.

Mobile Nurses

How does this expand our nurses’ roles? These nurses are tasked to care for a population of patients who are more mobile outside of the home, yet they benefit from focused care, targeted education and strategies to improve their well being.

In the Hospital to Home program, our nurses visit a patient several times within the first seven to 10 days, which is during the high-risk time period of rehospitalization. Nurses also supplement this with phone calls.

Home care nurses provide the total picture of a patient’s health. By being in the home, we have that true picture of a person’s sense of resources and how their environment may best be adapted to accommodate or improve healthcare needs. This provides a better opportunity to develop that relationship for health education and well being. 

Before these types of changes in nursing roles, patients overloaded with medical information still felt uninformed. On the whole, they often didn’t understand the discharge instructions or the process of care, and at times, they didn’t realize what was coming next. 

Nurse navigators and the Hospital to Home program eliminate that anxiety and avoid disruption in the care continuum. The patient is taken care of consistently and in a compassionate manner. Other hospitals can learn from our experience and establish programs that are similar to benefit their patients.

The expanding role of nurses is an exciting dynamic in our constantly transforming healthcare world. At the end of the day, registered nurses working to the fullest extent of their professional licenses in all areas of healthcare can only benefit the patient. The goal is to help patients through the medical process so they can heal without worry. +

Joan Coffman, FACHE, serves as president and CEO of HSHS St. Joseph’s Hospital in Chippewa Falls, Wis., an organization she joined in April 2008 as COO. HSHS St. Joseph’s Hospital is part of Springfield, Ill.-based Hospital Sisters Health System. Coffman also serves as vice president for physician relations for the HSHS Division Western Wisconsin. For more information, visit

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