C O N C O R D H O S P I T A L A N N U A L R E P O R T 2 0 1 7 47 MedicalHomeNurse NavigationProgram Nurse navigators play an increasingly important role in delivering care.They work with patients, families, caregivers, healthcare teams and community partners to help patients manage chronic illness or disease, understand treatment options and engage in wellness efforts. Nurse navigators in Concord Hospital’s Medical Home Nurse Navigation Program work with high-risk, highly complex patients who typically suffer from more than three chronic diagnoses including congestive heart failure, COPD and poorly controlled diabetes. Many patients also have behavioral health issues, most commonly depression and anxiety. Most are Medicare patients, but many also are Medicaid patients, uninsured or under- insured and commercially insured patients. These complex patients face what can seem like a maze of tests, doctor visits, hospitalizations and follow-up care.The nurse navigators ensure that patients do not enter the system alone; they answer patients’questions, address concerns and fears, communicate with other healthcare providers, help with scheduling, support caregivers and provide one-one-one education to help improve their patients’health. In 2017, medical home nurse navigators served 1,368 patients, which included a total of 28,482 contacts. Contacts include face-to-face meetings with patients and families, phone follow-up, coordination of care with other members of the healthcare team within Concord Hospital, CHMG, Riverbend Community Mental Health, CRVNA and multiple community and state resources. Coordination also includes participating in care planning/family meetings for seamless transition of care from the Hospital, skilled nursing facilities and acute rehabilitation to home. The team consists of 15 nurse navigators, including one in each of CHMG’s 12 primary care practices and in three specialty care practices – Concord Hospital Center for Urologic Care, Concord OB/GYN and Capital Region Palliative Care and Hospice. One licensed social worker works with the nurse navigators to address issues including homelessness and housing needs, food insecurity, guardianship and healthcare and medication costs. The social worker also helps with short- term counseling for some patients and with transition to long-term, consistent counseling support in the community. Care coordination focuses on whole- person care to address clinical/medical, psychosocial, socioeconomic, cultural and health literacy challenges that may affect the quality of care and how patients engage in their care.This focus allows for continued partnership with many community and state resources to address the patients’needs appropriately as a team. In 2017, CHMG also began developing a standardized nurse navigator performance report on specific patient populations to improve access to data and analytics. By tracking and reporting clinical, cost and quality trends across the Medical Home Nurse Navigation Program, CHMG will be able to see progress and track financial and quality performance to identify further opportunities to improve how we coordinate and deliver care and manage its cost. A separate nurse navigator team at Concord Hospital Payson Center for Cancer Care supports patients with breast, thoracic, prostate and head and neck cancers. TheRole oftheNurse Navigator face-to-face meetingswith patientsand families phone follow-up provide assistancewith transitionsof care communicate withother healthcare providers address concerns helppatients managecare helpwith scheduling support caregiver support food insecurity socialworker collaborates toaddress: shortterm counseling homelessness housing needs guardianship medicationcosts healthcarecosts