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Patient navigators

A new role to serve a growing need

By Katie Bausler, Community Relations Director

Around the world, the COVID-19 pandemic has magnified the plight of marginalized people in navigating their health care. The community we serve is no exception. Social workers work with patients to assess their needs and serve as their advocates in and out of the hospital.

On any given day, you'll find social workers throughout the hospital, working with doctors and nurses, physical and respiratory therapists, and others.

"For the inpatient social workers, we start the day with multidisciplinary rounds, reviewing patient goals of care and discharge needs," says Director of Case Management Jeannette Lacey.

Along with physicians, nursing staff and specialty team members, social workers assess the patient and prioritize and identify those who have certain needs and challenges and need discharge planning. They can help a patient access benefits or needed equipment or set up a plan for a patient being discharged for hospice care at home or in assisted living. They may coordinate with public health to track a person who has tested positive for COVID-19.

Help for people in crisis

For years, social workers and nurse case managers with the Bartlett Regional Hospital case management and behavioral health departments have worked with patients experiencing homelessness, patients with substance misuse issues and patients who show up in the emergency department (ED) in crisis.

"When people come into the ED in crisis, it may not be the best time to do logistical work with that person," notes Jeannette. "In those situations, we can create a care plan, and community navigators can link us back to that person when they are back in the community."

"Lack of housing is a huge driver of overutilization of the hospital ED," says Jeannette. "The community navigators' primary role is to connect people with housing and help fill the gaps."

"There's a lot going on with how kids and parents and families are handling the pandemic," she adds. "We partner closely with the Behavioral Health Team as they coordinate their crisis services with local agencies."

Behavioral health community navigators formed a crisis team made up of psychiatrists, clinicians and family navigators. Their focus is on helping stabilize people experiencing psychiatric emergencies. Such services are crucial in this time of skyrocketing suicidal ideation rates, especially among young people. They identify and accept community referrals and provide intensive case management for adults who are identified as high risk due to homelessness, substance use disorders and mental health disorders.

Community and clinical expansion

Bartlett social workers were part of a City and Borough of Juneau initiative to mitigate the impact of COVID-19 on the homeless population, including building a tracking system for positive cases to support isolation needs and identify exposures to other individuals. The Bartlett team was instrumental in setting up Centennial Hall as a shelter for people testing positive for COVID-19. It also partnered with CBJ Chief Housing Officer Scott Ciambor's team to make quarantine arrangements with hotels and develop new processes to flatten the infection curve, thereby preventing the hospital from being overwhelmed with cases.

Paramedics with Capital City Fire and Rescue (CCFR) are key to such efforts, making house calls to patients.

"We have built a much stronger relationship with CCFR paramedics and EMTs through an integrated mobile health team," notes Jeannette.

While the pandemic has exacerbated demand for CCFR and community navigators to help people who are uninsured or underinsured with filling health care gaps, filling prescriptions, completing paperwork and finding safe housing, the need for clinical patient navigators has emerged in other Bartlett departments. For example, obstetrics has added a clinical patient navigator to their team. Case Management is currently recruiting for a social worker patient navigator for the Bartlett Oncology Center. These roles are a hybrid of the community navigators and hospital case managers, working with patients in the community and on a more clinical level from a nursing or social work perspective.

Bartlett Beginnings navigator

Becoming a new mom is challenging for anyone. Mental health or substance misuse issues can make an already complicated situation even more complex. Thanks to a state contract and pilot program, patient navigator Rachel Gladhart has joined the Bartlett Beginnings team.

Rachel works with new moms to develop individualized family plans for substance abuse assessment and treatment, mental health treatment and services, housing and basic needs assistance, childcare, and other services needed to maintain a safe and stable environment for babies.

Establishing a relationship well before the baby is born is key, "because it's so hard to have some authentic, open conversation with somebody she's never met before," observes Jeannette. "Meeting with the mom and family early on allows the patient navigator to build rapport and trust."

The hope is the program may also mitigate postpartum depression in some patients.

Jeannette gives this hypothetical example: "Say a Coast Guard family comes to town, and maybe it's mom's first baby, and she doesn't have family here, and she feels isolated, and she is struggling or has a history of depression. Rachel can work closely with her to catch any potential severe postpartum depression."

"We are beyond excited to introduce this new program to the Juneau community!" says Bartlett Beginnings Director Lauren Beason. "The program will offer a model of care that highlights early connections, partnerships and supports that help build the foundations of healthy families."

Social work and behavioral health

More than 700,000 social workers nationwide make life better for others. Social workers are everywhere, including a growing force here at Bartlett Regional Hospital.

A strong mentor

A photo of Holly

Holly Cockerille, LBSW, CT, is the lead SW case manager of the inpatient units. She is a strong mentor and has supported new processes to meet the increased needs of community collaboration. She's been on the front lines, supporting patients and families from inpatient through transition to the next level of care.

A good listener

A photo of JustinaJustina Yung, LCSW, is a behavioral health therapist at Bartlett Outpatient Psychiatric Services and clinician for Psychiatric Emergency Services. She has been in the social work field for six years.

Justina was drawn to the social work discipline because she enjoys hearing about people's stories, their backgrounds, the changes they hope to instill in their lives and how she can help them.

Categories: Patient care

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