APRN Nurse Navigators? Help!

[traumaRUs, MSN, APRN]

My large (21+ MD, 1 PA, 3 FNP, 3 CNS) nephrology practice is developing a nurse navigator role.

The goal is to improve communication for our hospitalized end-stage renal disease patients and the outpt dialysis units (both hemo and peritoneal/home hemo). We are hoping this will decrease readmission rates by trouble-shooting from the inpt standpoint and carrying over to the outpt environment.

I have been doing lit searches and most of the nurse navigators I've found are oncology based and RNs.

Our goal is to have the APRN in the hospital providing education to the family/pt and then communicating with the outpt APRN so that the transition is seamless.

Our pts are very complex with multi-system end-organ damage and so are a challenge both in-pt (with many providers, poly-pharmacy, non-renally dosed meds, etc) and outpt (cont care, education, etc).

Has anyone heard of such a job description or know someone who fills this type of role currently?

Thanks to everyone for reading this - really appreciate it.

[Corey Narry, MSN, RN, NP]

I have no experience with such a role in my Critical Care specialty but I know many other services we deal with on a day to day basis have an RN Coordinator position or role that bridges the gap between hospitalization and chronic care management in the home. They also respond to patient calls about acute issues and concerns by the patient. Look into following a blueprint of the role from RN Transplant Coordinators and Heart Failure RN Coordinators.

[traumaRUs, MSN, APRN]

Thanks Juan - most of the navigator info I've found relates to cancer care and I have adapted some of that to the nephrology arena.

Thanks again