The Navigator plays a key role in ensuring safe and effective transfers of clients across the care continuum, serving as the bridge between the professional staff in a care setting, (e.g. hospital), the client and/or family and the community healthcare provider. The primary role for the Navigator is to inform and guide clients and/or family for an effective care transition, improved client self-management skills and enhanced client-healthcare provider communication.
The Navigator behaves in a professional manner, and consistently demonstrates and promotes the values of respect, honesty, care, and dignity for the client and all members of the healthcare team. The Navigator is committed to the constant pursuit of excellence in improving the health status of the patient and decreasing hospital readmission rates. The Navigator will be working in the hospital and community and must be able to make rounds in the hospital, make home visits and follow-up phone calls.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Run and screen daily census reports for potential client enrollments.
- Meet with client/family at hospital bedside to introduce the program and gather enrollment data.
- Evaluates aspects of each client’s condition, diagnoses, medications and support systems to formulate an individualized plan which will lead to successful outcomes in:
- medication self-management
- use of a dynamic client-centered record
- appropriate primary care and specialist follow-up
- knowledge of red flags
- Acts as a continuing resource for the client and/or caregivers for the entire 30-90 days post discharge period of transitional care. To increase continuity of care, it is expected that once an assignment is accepted the Navigator will continue with the necessary follow-up throughout the transitional care episode.
- Completes the necessary assessments and referrals.
- Provides feedback to the Transitional Care team if, during a home visit or follow-up phone call the client/caregiver indicates additional areas of needs or referrals.
- Maintains databases on care transition population and makes accurate and timely documentation.
- Collects data on clinical indicators to identify opportunities for improvement.