• Beth McCauley

The Passion for Care Navigation

I started my journey in Care Navigation over seven years ago, being hired to develop the “care coordination” role. “Care coordination” was a vague and distant concept at the time. I was given a desk, a computer, an opportunity and was told, “Ready, set, go!”


This is how I found my niche in nursing and my passion for what is called Care Navigation. It started with a focus on patients with diabetes, but it grew into so much more than that. The providers started sending me patients with complex issues who, in reality, simply needed a little extra attention that could not be given by their Primary Care Provider. It was here that I really started to gain a love for helping people navigate the health care system.


Soon I was working with two other nurses and we were diligently developing the Care Navigation program, focusing our work on any patient who was referred to us by the providers we worked with or those who had a hospital or Emergency Room visit. We were not just calling patients to see how they were doing, but we were looking at the whole picture. Were they still having symptoms that needed attention? Were they able to get their medications after going home from the hospital? And if not, why not? Was it a financial or transportation barrier? Did they simply not get a prescription from the hospital? Or, did they have the prescription and just not realize that is what it was? Were there community resources that would help them maintain their independence? It was a puzzle, and I was able to help put the pieces together. For the first time in my nursing career, I was able to have time, and take time, to focus on the whole person, not just the condition or acute illness. I began to develop rapport with my patients and they relied on and trusted me to help them overcome barriers. It didn’t take long for some patients to realize, “Hey, I have someone here who is on my side and who will listen when I need help”.


Not too long after the hospital follow up calls became routine, we added the Chronic Care Management program where patients could opt in to what is basically a health coaching program for patients with chronic illness. We were working with patients to help engage them in their own health, focusing on the health goals that were important to them, all while working with and keeping their primary care provider in the loop. It was a team effort with the patient at the center of it.


I am thankful for the opportunity I was given when a whole new world of nursing opened up to me through Care Navigation. Using my God-given talents, I want to help others through a difficult-to-understand health care system, during a time that is usually full of stress and uncertainty. I want to use my experience and expertise to be an advocate and help others overcome barriers. It is my passion as a nurse.


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