Client Navigator

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Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter.

Client Navigator - A position funded through Home Care and the Saskatchewan Ministry of Health that provides you with a single contact for persons needing to use community based services in the Cypress Health Region. The Client Navigator is a nursing professional to help you arrange for care and discharge planning.
Better Health

Marilyn Krause

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Client Navigator

  1. 1. Client Navigator, Cypress Health RegionMarilyn KrauseThis Session is sponsored by:
  2. 2. Marilyn Krause RN
  3. 3. A Ministry and Home Carefunded temporary position to“pull” surgical patients backto the Cypress Health Regionfrom Tertiary Centers as partof the Surgical Initiative.
  4. 4. Acute LTC ProgramHome care
  5. 5. UrbanRuralCHRCustomers
  6. 6. CNAll Dischargeplanning teamsRehabHome Care+EMS-MHSFacilities
  7. 7. TertiarypatientCHR-UrbanLTCAcuteCHR-Rural Integrated
  8. 8. CYPRESSREGIONALHOSPITAL(CRH)RegistrationHow aretheyinvolved??
  9. 9. THENWHAT???
  10. 10.  Social Workers Rehab-PT/OT (whichInclude MHS-MobileHealth Services in ruralsites.) Case Managers Home Care Nurses EMS-Falls Prevention& home safety checks
  11. 11. What is this committee for?Patients are assessed and presented for programbeds (convalescence) or LTC placement. Tertiarypatients could be transferred for these reasons.Who is on the committee?Director, Home Care Manager -Chair, ClientNavigator, Case Manager.How are they prioritized?Based on need, assessment tools and chronologicalorder. Patient is given the most appropriate bed inthe region by the Client Navigator. Client isnavigated in and through the system.
  12. 12. Discharge Planning includes the Patient and their Families.Discharge Planning Teams
  13. 13.  Procura-client information/dated notes Wincis-bed availability LTC Database-bed flow CN Citrix program-Tertiary transfers to CHR MDS-Assessment information for placement Sharepoint-Hoshin, Home care, CAPC,information sharing with colleagues Mobile Health Services (MHS)-Citrix for Fallstracking. Reports can be generated from all the aboveprograms for Statistics and Quality.
  14. 14.  To be part of the Discharge Planning committeeand discharge teams to standardize discharges. Review readmissions-Are patients in theappropriate beds for recovery? EMR-protect patient’s confidentiality but alsocommunicate and share information in the circleof care. Assist patients to navigate through the healthcare “maze” reducing hazards/barriers andburdens for the patient and their family. Patient centered v.s. Process centered.
  15. 15.  It is an honor to be able to speak to the efforts, support and compassion that Iwas provided when looking to have my mother transferred to Swift Current fromSaskatoon. We had moved mom up to Saskatoon when it became apparent thatshe could no longer support herself and required help with food, medications, etc.She lived in a private level 1 care home for around 4 years. In December, 2012 shegot quite sick and was admitted to St. Paul’s Hospital in Saskatoon where shespent about three weeks recovering. When she was finally stabilized, our familyfelt it was best to have her transferred down to Swift Current as this was herhometown and she was requiring level 3-4 care, which was available in SwiftCurrent. At that time, I approached Marilyn to see if this was possible and how Iwould even begin to make it happen. It was then I truly understood not only thescope of work of a Client Navigator, but also the exceptional way that Marilyn wasable to clearly explain the process and be there with me every step of the way.Within a matter of days, I had my mother back in Swift Current, first in ourhospital and then into the Prairie Pioneer Lodge where she is getting the care sherequires and is being treated like a queen! The position of Client Navigator andMarilyn Krause in particular is a huge benefit to our Region and I can’t thank herenough for the work she puts in!Grant Browne Medical Affairs Coordinator Cypress Health Region
  16. 16.  In July 2012 my father had surgery in Saskatoon. Prior to his surgery we had made contact withMarilyn Krause, Client Navigator to determine how we could have him back in Swift Current as soonafter surgery as possible, and what was available to support my parents, and our family in his recovery.Marilyn was able to arrange for him to be admitted to a program bed at the Palliser Regional CareCenter for about a week of rehab and recovery, before he returned home. Marilyn’s position of Client“Navigator” is exactly that – she was our navigator thru the process – she offered information, options,advise, people to contact, support and encouragement. We had a few surprises with somecomplications after surgery, which delayed his return slightly, and some “not so cooperativecircumstances with the Saskatoon physician and hospital”, but with Marilyn’s help we were able to havehim transferred by ambulance and he very much enjoyed the time he spent in the Palliser with thatextra recovery time, and our whole family was more comfortable that he was “ready to go home”,which is about 25 miles outside of the city. Even though I work in the Health Care system, and have some knowledge of how to access theservices provided, I think the Client Navigator position is extremely valuable for patients and theirfamilies. Marilyn does an excellent job in this role, and my parents and family were very happy to haveher assistance and expertise. Shelley Dawson-Briere, Senior Labour Relations Consultant-CHR
  17. 17. The Client Navigator is the link between allhealth regions and disciplines in thecommunities we serve.
  18. 18. Client Navigator
  19. 19. Thank you for your attention.**Remember to have a great day!!The End

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