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PH Team Nurse Navigator

Sharon Jones


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Conference: 2015 PH Professional Network Symposium

Release Date: 09.17.2015

Presentation Type: Abstracts

File Download: 2015 Symposium Abstract - 1013

File Size: (242 kb)

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To describe the role and responsibilities of the pulmonary hypertension (PH) nurse navigator as the nurse coordinator for the PH team and its importance in management of the PH patient.


The Christiana Care Health System (CCHS) PH program sees approximately 100 adult pulmonary arterial hypertension (PAH) patients and provides all diagnostic testing as well as all forms of PAH treatment: oral, inhaled therapy, subcutaneous (SQ) and intravenous (IV) therapies. There is a dedicated outpatient clinic within the hospital and patients are cared for and treated by the same team members whether they are inpatient or outpatient using a patient navigation model. Pivotal to the PH team is the nurse navigator, who is the clinical coordinator for the team. The rest of the team includes: the medical director who is a pulmonologist, a nurse practitioner, a nurse clinical specialist, a pharmacy specialist and a research nurse. The nurse navigator is the triage person for the PH team and coordinates all patient care activities before, during and after the diagnosis of PAH is made. A review of literature regarding care coordination for chronic diseases reveals that programs utilizing patient navigation principles can realize better patient outcomes, increase patient satisfaction, and also decrease institutional financial burdens by increasing timely access to care.


The CCHS PH program was established in 2009 and rapidly grew in the number of patients from this time through 2011. The medical director had part-time assistance from one of the pulmonary practice nurses, and ultimately solicited help from hospital case management to assist with drug enrollments. The full-time nurse navigator role began in 2012 and continues to this day with responsibility for all PAH patients.


The nurse navigator role has been successful in being the point of contact for the CCHS PH team, especially for patients along the entire continuum of their PH treatment. The nurse navigator is the essential liaison between care settings for the patient so that vital information regarding the PH treatment plan is not lost as the patient transitions from one care setting to another. In addition, PH patients receive timely enrollments for PH therapies and referrals for pulmonary thromboendarterectomy and lung transplantation.


A designated nurse for the PH program is crucial to the care coordination of PH patients who need timely access to care and drug therapies. The nurse clinical coordinator role can guide patients through all aspects of PH care and treatment and the PH team needs the type of structure that this nurse provides. There is evidence that when patients receive patient navigation services, they are more satisfied with care and more likely to adhere to the treatment plan. Therefore, both the PH patient and the PH team benefit from having a PH nurse coordinator and an ideal treatment team for PH patients can be realized.