Yale New Haven's nurse navigators assist stroke patients

Stroke recovery can be a long and complex process for patients and caregivers, so Yale New Haven Hospital is deploying nurse navigators to help ease the transition between sites of care.

The hospital used nurses as care navigators in pediatrics and oncology before offering them to stroke patients starting in May 2016, according to an article from the New Haven Register. They meet with patients even before a stroke is formally diagnosed.

Care navigators can improve patient engagement and outcomes. And research suggests that they can reduce emergency department overuse and hospital readmissions, too. Navigators are also effective in helping poor patients who may not get sufficient care and can reduce delays in treatments and diagnoses.

Stroke symptoms can differ widely between cases, so the first thing Yale New Haven’s navigators do is offer patients and families an idea of what to expect. They then work alongside physicians and assist in “focusing on the gaps” in care.

“We can continue educating them to discuss stroke and what their expected hospital course is going to be, especially for the first 24 hours,” Kelsey Halbert, R.N., one of the navigators, said. “They will be seen by countless providers, so it’s nice to establish a familiar face.”

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Some hospitals have found success using former patients as navigators and training students to serve as health coaches. At Garrett Regional Medical Center, a 55-bed rural facility in Oakland, Maryland, five volunteer navigators help their fellow patients traverse the healthcare system, and the Breast Cancer Center at the University of California, San Francisco deploys the Patient Support Corps.

At Yale New Haven, the nurse navigators also ease the transition from hospital to home for patients, according to the article. They schedule home health nurses and physical therapy appointments and keep primary care doctors in loop—or, when needed, connect patients with a PCP when they don’t have one.