Nurse Navigators, Australia

Good Health and Well Being
Case Study Submitted by: Christopher O’Donnell, Director of Nursing at Queensland Health, Office of the Chief Nursing and Midwifery Officer, Nurse Navigator Program

John is 59 years of age and lives in a remote area of Queensland. Australia. He has a background of chronic heart disease, peripheral vascular disease and has poorly controlled type 2 diabetes mellitus. Increasingly short of breath, John visited his local health centre and was admitted to hospital for treatment for pneumonia.

John is not a unique case. In Australia, due to the complexity of health needs and access to health services, the number of patients attending emergency departments on a regular basis is increasing. This is a costly form of treatment and governments are recognizing the need to prevent the overuse of expensive hospital-based services.

In order to address this critical issue, Queensland has introduced a Nurse Navigator model of care into the public health system. The Nurse Navigator’s role is to support the patient’s journey through a complex health system. They focus on the patient’s entire healthcare journey, working across providers and sectors to ensure that the right care is provided at the right time and in the right place. As the central point of contact for the patient among the collaborative team, the Nurse Navigator educates patients and enables them to self-manage their health as much as possible, improving patient outcomes and enabling improvements across the system.

John was assigned to a Nurse Navigator who helped identify and coordinate access to the services that John required. As a result, John wasn’t left on his own when he was at his sickest and most confused. Taking into account John’s medical history and remote location, the Nurse Navigator helped ensure that John would receive the care he needed, when and where he needed it.

The Navigator took care of hospital admission, developed a care plan and became John’s central point for communication and engagement with all stakeholders with a role in John’s care, ranging from his local health service, to his cardiology and endocrinology specialist nurses and doctors hundreds of kilometres away, as well as his family members.

Having identified John as a high-risk patient, the Nurse Navigator maintains regular contact with him to ensure he is safe and his health needs are being met. This end-to-end approach will help John overcome any potential barriers to receiving the care he needs, and helps him avoid unplanned readmissions to hospital.

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