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​Hi Mike,

 Do you have a job description for the Navigator position?

Thank you

I would love an example of the readiness assessment if possible

​Hello Diana,

At our facility we have hired an RT Navigator (myself) to work on reducing COPD hospital readmissions. Here is what I have done thus far:

1) I have worked extremely hard at trying to "break the silos" and forge strong clinical relationships among RT, RN, Case management, Physicians, and Administration. This is vital to the success of hospital readmissions because it truly takes a team effort. 
2) Next, I focused on monitoring who came into our facility and what kind of care they received. This required me to work with the quality department and get a direct patient list sent to my email showing all of the pulmonary patients currently admitted.
3) Then, I will go round on those patients and interview them. Things I looked for was: smoking history, smoking cessation, home life, oxygen requirements, medications, etc. This was a perfect opportunity to load them with education and assist in the discharge planning process collaboratively with case managers. If pulmonary rehab was an option then i would get them the prescription prior to dishcharge.
4) I would then hold weekly meetings to review the patients seen that week and it would be a team of: RT, Case manager, Pulmonologist, Medical Coder, and a person from quality. During these meetings we would verify proper diagnosis and proper care.
5) Post-discharge calls to patients were initially part of my role however, they had a special department who did calls so that become unnecessary.
6) For frequent readmission patients i would meet with the Chief of Medicine and we would reach out to the patient's PCP to try to come up with a better plan.

Overall, this has proven to successful but it could be even better! I feel my next project will be implementing a COPD discharge readiness test to help ward off premature discharges.

Hope this information helps, it's honestly more work than i can even sit here and type but this should help guide you.

Encore LLC

They have a great program - tested - track record - great results

​We have a COPD Assessment done on frequent re admits.  With the results we determine teaching needed for the patient.  If interested I would be glad to share.
Autumn
rrt@waynegeneralhospital.org

​I am interested in this also. We do not have a COPD educator or navigator and are not able to obtain one at this time. Any direction would be greatly appreciated.