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Blog & News

Taking the final mile with Population Health data findings – Nurse Navigation is one avenue

More and more frequently, our current and prospective employer group clients will ask us what we see as the most effective avenues to support employees and members who have been identified through analytics for outreach and support. How do they “take the final mile” for those with chronic conditions and co-morbidities, inappropriate ER utilization, gaps in care, medication risk(s), potential pain script issues, and predicted events such as hospital admissions, re-admissions, heart attacks, strokes and more.

There are many avenues that our clients are taking to get individuals the education and support they need. Nurse Navigation is one of the most effective programs that we’re partnering with our clients to launch and manage. We thought this would be a good topic to cover during National Nurses Week.

Employers are engaging Nurse Navigators (telephonic and in-person) to help individuals understand their health conditions, their providers’ treatment plan(s), and what is involved in complying with the best practices inherent in preventive health testing and caring for specific health conditions.  Additionally, they support lifestyle modification in such key areas as managing stress, nutrition, activity, sleep and rest, life balance, tobacco cessation and setting realistic goals.

They are also able to direct individuals to Plan, provider and local resources for additional support. An example of this direction is through coordinating with the insurer on large case management after the identification of those who are slipping through the cracks.

The most successful Nurse Navigation programs tailor actions to the member’s pace in a way that best fits individual lifestyle and cultural considerations. Effective Nurse Navigation starts with an analysis of the member profile, which incorporates risk factors, care gaps, claims history (medical, pharma, vision, dental), treatment effectiveness, medication compliance, providers and much more. This is an area where Advanced Plan for Health’s Poindexter analytics plays a critical role.  Once the profile is known and the opportunities are identified, individualized action plans may be developed to enhance quality, cost and member experience.

Nurse Navigators are able to take an employer’s strategic health plan goals and work creatively with their team to develop activities that enable them to engage with targeted, willing individuals, who will benefit from participating in ongoing coaching sessions. Programs are designed to help individuals to reach personal health goals, understand provider treatment plans, and learn how to comply with best industry health practices, both individually and environmentally.

The caring, compassionate and influential approach of nurses makes them particularly suited for all of these activities.

One large employer client with scattered geographic sites is benefiting from having nurse care navigators at each area hub to engage individuals one-on-one, present health topics at safety meetings, help management with on-site health practices that need to be changed, and facilitate onsite events and communication that promotes health in an interesting way.  Nurse navigators also support biometric screening and other activities at on-site health fairs.

An example of a successful finding of the Nurse Navigator team was to minimize heat stroke risk in the hot days of Summer by modifying break times.

The program has been an ongoing positive influence at jobsites leading to knowledge that – “my employer cares about me.”

To find the Nurse Navigation resources they need for these critical programs, many employers are turning to local providers and resources. In fact, some of our hospital and provider system employer clients who initially formed Nurse Navigation programs to support their own employees and members, are now offering this service to local employers.


If you’re interested in learning more about how Nurse Navigator programs are being planned, launched and run across our client base, or how our Poindexter analytics platform identifies targets and measures results, please contact us here.

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