Care Navigators Go the Extra Mile for Heart Failure, COPD Patients

Tom Lowndes is fighting heart failure, but he’s quick to tell you about the team in his corner.

It includes his cardiologist, Joseph Ayoub, MD. There’s also the staff at the Methodist Jennie Edmundson Hospital Cardiopulmonary Rehabilitation clinic.

But the key point of contact, Tom said, is Kathy Sindelar, BSN, RN.

As a care navigator, Sindelar is essentially an on-call partner for patients as they face the challenges of managing their conditions and navigating the complex world of health care.

Every step of the way, Sindelar has been a constant for Tom: from his diagnosis at the hospital in January to every follow-up cardiology appointment at Methodist Physicians Clinic Council Bluffs. Having that personal advocate as part of his care team has been invaluable.

“I’m just totally impressed with the doctor and nurse relationships that I’ve had through this experience,” Tom said. “They’re very practical. They’re very personable. They’re available.”

Serious Goals, Personal Touch

The Methodist Physicians Clinic Heart and Lung Wellness Program began in the summer of 2016 with four nurses, known as care navigators, focusing on two groups of patients: those with heart failure or chronic obstructive pulmonary disease, commonly known as COPD.

“It’s crucial for their well-being to not go back into the hospital or the emergency department,” said Laurie O’Byrne, MS, BSN, RN, Methodist Physicians Clinic’s administrator for Population Health and Patient Experience. “Everything that we can do to manage their disease at home or where they’re most comfortable, where they can maintain their independence, that’s a win for the patient.”

The program has grown to six nurses working in Omaha and Council Bluffs. Each navigator works with about 100 patients from across the region – from Fremont to Red Oak. 

A patient’s introduction to the program often begins during a hospitalization. They’ll meet with a navigator who explains the program, identifies the patient’s needs and challenges, and starts the process of educating them on their condition. 

The goal is to provide a smooth transition upon discharge and set up a patient for better long-term results. The relationship isn’t temporary – it can span years.

“It makes them feel like somebody is going the extra mile and providing The Meaning of Care,” said Terry Meidlinger, BSN, RN, a care navigator who works with patients at Methodist Hospital and Methodist Physician’s Clinic Heart Consultants at Westroads Office Park.

Communication Is Key

A care navigator also attends cardiology and pulmonology appointments with a patient, offering support and continued education. But it’s the contact between appointments that can reap some of the greatest results. 

Navigators are always working the phones. They check in on patients monthly, weekly or more often, then consult with their doctors. Their calls often lead to over-the-phone adjustments of diuretic drugs for heart failure patients or coaching on how to manage aggravated COPD symptoms. Patients and their caregivers are also encouraged to call the navigators with questions.

“They like having that connection. I think there’s a lot of comfort in knowing that if they can’t get answers any other way, they have us to call,” said Laura Swartz, RN, who sees patients at the Westroads clinic.

Navigators also communicate with local pharmacies, home health services, and doctors and specialists outside Methodist. 

“The work they do for patients is tremendously beneficial,” said cardiologist Michael Dehning, MD, who is based in the Westroads clinic. “They put in the extra effort to identify what needs to be done.”

There Throughout the Journey

On a recent morning, Swartz called a patient with heart failure and COPD to check in. Things were going OK for Don White, so she reminded him and his wife, Jean, about his upcoming cardiology appointment. But later that day, during a home health visit, a nurse noticed Don was more short of breath than usual and had rapidly gained weight, a sign of fluid retention.

The nurse contacted Swartz, who quickly set up an appointment to see Don the next day. About 40 minutes after Don arrived to see Swartz, he was finishing an IV treatment that likely prevented a longer, costlier hospital stay. Jean was relieved and thankful for Swartz’s role in getting Don seen so quickly. 

“Your life is prolonged with a nurse like her,” Jean said. “She keeps things going. She’s very concerned. And I always tell her I appreciate everything she does.”

It was the latest meeting in a relationship that dates to the beginning of the program. Don called Swartz and Dr. Dehning part of his “support group,” and he said he especially appreciates their frank discussions. 

“You just want somebody to look at you and tell you the truth,” he said.

This spring the couple and Swartz started discussing hospice. That, too, is part of the effort to help patients best manage their conditions.

Don started hospice care in May. Days before he died, he called Swartz to tell her one final time how much her care meant to him. Dr. Dehning also called to let Don know he was thinking of him.

“This is what we do,” Swartz said. “It’s not just the outcome, but the whole journey. And Don and I and Dr. Dehning have all been on that journey.”

Impacts Large and Small

Back in Council Bluffs, Tom has seen tremendous results since his diagnosis. His weight is down, his breathing has improved, he’s exercising daily, and his eating habits have been “revolutionized.” Plenty of credit, he said, goes to Sindelar.

Whether it’s big health changes like Tom has seen or simply answering a patient’s question, Sindelar is proud of what the navigator program has been able to accomplish.

“I think it’s rewarding to see that you’re making a difference,” Sindelar said. “I’m here for the patients and want them to have the best outcome, stay out of the hospital and feel the best they can.”

Said Tom: “I want to get well and stay well, so I do what she says. She is that person who has been a subtle reminder of all the things I need to do to improve.”

Photos by Daniel Johnson and Chris Thompson.