What does a transition navigator do?

Caring for communities

When facing the transition to end-of-life care, it’s common for patients and their loved ones to feel uneasy or have questions about the hospice process or timeline. For Enhabit Home Health & Hospice Transition Navigator Jordan, she decided she wanted to help people through this period of life after one experience with an emergency department patient.

This patient frequently returned to the hospital. Despite all her medical problems and continuing family burdens, no one discussed hospice with her.

“The last time she came in, there just wasn’t much left to do and she was declining pretty quickly,” Jordan said. “I ended up talking with the family and walked them through hospice. They were reluctant at first but open to talking.”

“I followed up with her a few times after she was admitted to hospice. She was home and happy and it just seemed to be the best-case scenario for her. Her family told me how it was so much better being at home around family and not continuing to come back and forth to the hospital.”

From that point on, Jordan knew she wanted to continue helping patients and their loved ones navigate the end-of-life journey.

What is a transition navigator?

At Enhabit, our transition navigators are experts in transitional care and providing comfort to patients and families at the end of life. Similar to care transitions coordinators,  transition navigators are a resource to patients. They are available to meet with providers, patients and caregivers to help mitigate any risk related to transitioning home.

When transitioning home to begin hospice care, the end-of-life journey may provoke worry in many patients and caregivers. Transition navigators are key to this step, serving as a wealth of knowledge and comfort.

“It’s all about reminding them that we are there for them and are going to walk alongside them and hopefully alleviate some of the tension and nerves they have about going home and what that’s going to look like,” Jordan said.

When extra attention is placed on transitional care, patients are less likely to return to the hospital. This leaves them more time with their loved ones as they near the end of life.

What does a transition navigator do?

Transition navigators represent their local Enhabit office in external transitional care activities. They also keep relationships with professional contacts such as patients, families, physicians, hospitals, facilities, senior living communities, professional associations and similar health groups.

Throughout their day, they integrate clinical guidelines, protocols and other metrics to develop patient-centered transition plans that promote quality and efficiency. Additionally, they serve as a public awareness representative and are responsible for education related to hospice services.

A woman wearing purple scrubs is on the phone with a patient, representing what a transition navigator does

Although they are busy communicating throughout their day, Jordan says the importance of a transition navigator is in providing education for patients and their families.  

“I always assume people don’t know anything about hospice because I’ve found that what people think about hospice is different for every person,” she said. “So, I just start from the beginning and ask them what they know and then I tell them what we can do and the resources we can provide.”

Then from there, Jordan sets expectations for both the patients and their loved ones so that they can feel more at ease about the end-of-life journey.

Transition navigators are a piece of the puzzle to the entire hospice care team, but they oftentimes connect the dots to the bigger picture of the resources that hospice care can provide.

“I’ve found that a lot of doctors think they know what hospice can do but they really miss the mark on the whole picture for the patient,” Jordan said. “Yes, going home to die is part of it but that’s really just a tiny piece of what we do.”

What is it like to be a transition navigator?

Transition navigators get to leave an impact on many patients and families each day. However, Jordan’s favorite stories are the simple ones.

“Sometimes families are terrified to hear the word hospice,” she said. “And then we really just love on them and take care of them and they use all of our resources like grief counseling and social work. When you help them do the small things that everyone forgets and then add it all together, it makes one giant weight that gets lifted off the patients.”

When she can show patients and their loved ones what hospice really is and what all it has to offer, Jordan says it feels really rewarding.

“I love when I can talk with the family and they say they didn’t want hospice but looking back and seeing all the help they got and getting their loved one home, now they would never change that,” she said. “That brings me tremendous joy.”

How do I start my career in hospice?

Although transition navigators play a large part in a patient’s hospice journey, Jordan says that it wouldn’t be possible without the rest of her team.

“All the small things come together in hospice care,” she said. “It’s not just my role, it’s the office staff, the nurses, the chaplains. When everyone is united and works together, it is so great for all the families.”

For Jordan, meeting the families and helping meet their needs is her favorite part of her role.

“I love talking to the family and asking them the number one thing they need and being able to check that off,” she said. “The two things that need to be taken care of the most are babies and those at the end of life. When it comes full circle and someone can step up and help a family member check off those boxes of greatest needs, I think that’s the biggest joy in the job.”

At Enhabit, transition navigators are registered nurses, licensed vocational nurses, physical therapists or occupational therapists with 1-2 years of home health or hospice experience and a strong understanding of hospice guidelines, as well as transitional care best practices.

To learn more about hospice career opportunities at Enhabit, search our open career opportunities near you or sign up for job alerts by texting “CARE” to 98199.