Care Transitions in NVAF: Role of the Patient Navigator

Jaime E. Murillo, MD; Juvairiya Pulicharam, MD; and Peter Salgo, MD, emphasize the role of the patient navigator in preventing events and improving outcomes for patients with nonvalvular atrial fibrillation through health care transitions.

Peter Salgo, MD: I want to get back to this navigator question. Is there a protocol that should require this navigator to get integrated and involved right away? Do you have those protocols?

Juvairiya Pulicharam, MD: Yes.

Peter Salgo, MD: Should they exist?

Juvairiya Pulicharam, MD: Yes.

Peter Salgo, MD: How do they work?

Juvairiya Pulicharam, MD: We have protocols for transitions of care. That’s very important for the navigator, or transition coach, or health coach, or coordinator. Communication is supposed to happen, but it’s not happening. For patients, especially when they’re discharged, we do have a teach-back method. We talk to the patients. We explain things to the caregivers. We ask them questions. Because of the polypharmacy, a new medication is prescribed. There’s medication at home. There are supplements that they’re taking, which they don’t talk about because they’re afraid to tell their physicians about them. So, in our case, we have the navigator, or the health coach, or the transition coach go to the home of the patient.

Peter Salgo, MD: They go to the home of the patient?

Juvairiya Pulicharam, MD: Yes. For some high-risk patients, this is a possibility. If not, we at least go over everything on the phone. So that’s a communication effort to keep continuity of care. And then, we have the discussion with the primary care physician. That’s very, very important.

Peter Salgo, MD: For a patient who comes in with a critical illness, such as bleeding on anticoagulation, the 3 words that I worry about are, “lost to follow.” That’s creepy. They’re out there in the ozone on stuff. Some have your signature on it.

Jaime E. Murillo, MD: You’re absolutely right. That’s one of the beauties of how you structure healthcare payments—how it can affect the way you care. We always knew about the separation between in-hospital care and outpatient care. Once you get out of the hospital, you are out of my sight, right? With this 30-day readmission, and so on, maybe we should pay attention. And that’s why we have the navigation coach, or the transition coach, and so on. Finally, we understand that the patient’s continuity of care is critical to outcomes. We now have the ability and need to coordinate that discharge with what’s going on with the patient, primary care physician, and pharmacist.

Juvairiya Pulicharam, MD: Yes. It’s not rocket science. It’s basic stuff that’s not happening.

Peter Salgo, MD: Like what? Give me an example of what’s not happening.

Juvairiya Pulicharam, MD: Communication—that’s not happening. Really, making sure that patients don’t have drug—drug interactions. Then, education about their disease state. For example, if you have an atrial fibrillation patient and you discharge the patient thinking, “OK, the patient is on anticoagulation and I don’t want to deal with it,” and you don’t discuss anything with him/her, that’s an opportunity lost, right there, because they would have listened to you. So, I think there’s a lot of opportunity and a lot of chances where we can improve care. If you talk to an atrial fibrillation patient about stroke and really explain things in ways that they can understand, I think they would be more compliant. We have seen that in our real-world atrial fibrillation registry. For a certain percentage of patients, in those who were educated, we saw excellent results when we followed those patients.

Peter Salgo, MD: My cardiologist friends talk about CABG [coronary artery bypass surgery] patients, MI [myocardial infarction] patients, and failure patients who are admitted with decompensation as having teachable moments.

Jaime E. Murillo, MD: So just include the patient in their care, right?

Peter Salgo, MD: Right.