A 42-year-old hospital patient with a new diagnosis of insulin-
dependent diabetes needed medications and supplies. He 
had recently been released from prison and didn’t have 
a job or health insurance. The staff at Alamance Regional 
Medical Center knew to call Tiffanie Robinson, BSN, RN, 
Nurse Navigator for Underserved Populations. She was 
able to connect the patient with resources for medications 
and supplies, establish primary care and access nutritional 
resources to manage diabetes. She also helped him obtain a 
CPAP machine, which he had been unable to get for over a 
year, and assisted with his search for employment. Today, he 
has a job, is living in a better environment and has been able 
to purchase a car. 
The Nurse Navigator for Underserved Populations began as a 
pilot program for Unit 1C at Alamance Regional in September 
of 2024. Patients with mental health or addiction diagnoses, 
a history of incarceration or those experiencing homelessness 
qualify for the program. Robinson ensures patients have the 
resources needed to manage their current condition and 
services to overcome barriers to continued health. 
•  Patients are followed by the nurse navigator during 
    hospitalization and connected with community resources 
    and follow-up appointments at discharge.
•  Follow-up phone calls are completed at 15, 30, 60 and 
    90 days after discharge. More frequent communication is 
    provided for patients with higher acuity issues.
•  Patients are also called after each scheduled appointment to 
    address any questions or reasons for non-adherence.
Two areas of opportunity have also been addressed. 
•  At the start of the pilot, wait times for outpatient 
    appointments following hospital admission, especially for 
    unestablished patients, were four to six months. Robinson 
    worked with outpatient practice leaders to reduce the wait 
     to one to two months. 
•  While 231 patients endorsed active substance abuse, 147 of 
    them refused substance abuse treatment programs. Plans 
    call for a full-time addiction medicine practitioner to begin 
    work in late 2026. This role will help reserve spots for 
    patients who need immediate follow-up after hospitalization.
“Tiffanie serves as a critical lifeline for some of our most 
vulnerable populations,” says Amanda Perez, RN, Charge 
Nurse, 1C, Alamance Regional. “Her role is not just clinical; 
it’s transformative. What sets her apart is her unwavering 
commitment and advocacy. She navigates complex systems 
with persistence and creativity, breaking down barriers that 
many of these patients face daily. Her work directly reduces 
hospital readmissions, improves continuity of care, and 
most importantly, restores hope for individuals who often 
feel forgotten. She embodies what nursing is at its core—
compassion, advocacy and resilience.”
Restoring Hope and Health With Advocacy
New Nurse Navigator Role at Alamance Regional
Nurse Navigator for Underserved 
Populations Lowers Readmission Rates
•  537 patients have been enrolled. 
•  Before the pilot, patients who fit program 
    criteria had a readmission rate ranging 
    from 41% to 45%. 
•  In the first 90 days, readmissions for the 
    target group dropped to 11.02%. 
•  Currently, the average readmission rate 
    is 14.56%. 
OUR STRENGTH AND RESILIENCE
Tiffanie Robinson, Nurse Navigator for Underserved Populations, 
at the Nursing Excellence Showcase
7
NURSING IMPACT REPORT 2025

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