INVESTIGATING THE EFFECTIVENESS OF NURSE NAVIGATORS IN IMPROVING CARE COORDINATION AND REDUCING HOSPITAL READMISSIONS

Abstract

Hospital readmissions are a significant challenge for healthcare systems, with implications for patient outcomes and costs. Nurse navigator programs have emerged as a promising approach to improving care coordination and reducing readmissions, but evidence on their effectiveness in general patient populations is limited.

Objective: To evaluate the impact of a hospital-wide nurse navigator program on 30-day readmissions and patient-reported care coordination in a diverse patient population.

Design: Mixed-methods study with a quasi-experimental design and qualitative provider interviews.

Setting: Large, urban academic medical center.

Participants: 1,258 adult patients admitted to medical, surgical, or cardiac units and 25 healthcare providers.

Intervention: Nurse navigator program providing individualized care coordination and support from admission to 30 days post-discharge.

Main Measures: Primary outcome was 30-day all-cause readmissions. Secondary outcomes included 30-day emergency department visits, patient-reported care coordination (Care Transitions Measure), and discharge preparedness (B-PREPARED scale).

Key Results: The 30-day readmission rate was 18.2%. In adjusted analyses, the intervention group had significantly lower odds of readmission compared to the comparison group (OR 0.72, 95% CI 0.55-0.94). Intervention patients also had lower rates of 30-day emergency department visits and higher patient-reported care coordination and discharge preparedness. Qualitative themes highlighted the importance of navigators as bridge-builders, challenges of role clarity and integration, and the need for dedicated resources and training.

Conclusions: A nurse navigator program reduced readmissions and improved care coordination in a diverse patient population. The results support the effectiveness of nurse navigators as a strategy for improving transitional care and patient outcomes.