Nurse Navigator Program for CHF Patient Management

This case study details the implementation of a Nurse Navigator program at Magnolia Regional Health Center aimed at improving medication adherence and reducing hospital readmission rates for patients with congestive heart failure (CHF). The program utilizes a data-driven approach, leveraging population health management tools to monitor patient adherence and access prescription fill history in near-real time. The process involves three key steps: in-hospital identification and enrollment of eligible patients, post-discharge follow-up within 72 hours, and long-term follow-up within 30 to 60 days post-discharge. Results from the program demonstrated significant improvements in medication adherence, with a marked decrease in 30-day readmission rates from 24% to 15%. The study outlines additional plans to expand the program to other chronic conditions and submit findings for peer review to promote broader adoption among health systems. The positive outcomes indicate that structured, multi-touchpoint interventions can effectively enhance adherence and improve overall patient care.