The Role of the Nurse Navigator in the Management of the Heart Failure Patient.

Today's health care systems are faced with challenges to transform health care delivery and provide quality and valued services for the heart failure population. These challenges require collaboration and the development of strategic processes that will redefine best practices. Implementing a multidimensional nurse navigator transition program is one approach to facilitating cross-continuum of care. Such a program has been proven to significantly reduce 30-day all-cause hospital readmissions, enhanced self-management skills, and improved follow-up compliance. This transitional care model can be used to address the needs of all patients with chronic conditions.