Jane*, 82, was living outside of Lubbock, Texas, with a history of uncontrolled diabetes, high blood pressure and heart failure when she was hospitalized with lower extremity cellulitis, a common and potentially serious bacterial skin infection. After being discharged, Jane’s blood sugar was dangerously high, causing her to feel so dizzy that she couldn’t drive, cook or do normal, daily activities. Her unmanaged conditions caused swelling in her legs and discomfort in her feet that made it difficult for her to walk or even wear shoes.
“I couldn’t drive to the grocery store to buy food, or stand long enough to cook,” says Jane. “I had to rely on my son to bring me meals – I hadn’t even been in my kitchen for months.”
Jane was referred to the Patient Navigation Team at Covenant Health, a member of the PSJH family of organizations. The Patient Navigation Team, comprised of nurses, social workers and a care integration assistant, helps patients navigate the health care system and ensures they have the knowledge and skills to make positive changes. This includes providing education on disease management and medication adherence, ensuring appointments are made and kept, and connecting patients to appropriate community resources including food assistance, medication assistance and counseling services.
Many of the patients who find their way into this program have chronic conditions or social issues (mental health, low-income, food insecurity, etc.), and a lack of knowledge regarding available resources. The guidance provided by the Patient Navigation Team is invaluable to patients who could otherwise get lost in the complexity of the health care system, regularly visiting the Emergency Department (ED), and having little hope of improving their health and well-being on a fundamental level.
“Services like those being offered by the Patient Navigation Team directly address a critical need in our local community, and in our country,” says Tavia Hatfield, Covenant Health’s regional director of Community Health Investment. “Emerging research continues to emphasize the importance of one’s environment and other social factors as key drivers to health outcomes. For the 133 million Americans living with chronic conditions, and the millions of others living with unmet social needs, being given the power of knowledge and access to resources can vastly improve their quality of life.”
Making a Difference, One Patient at a Time
Licensed vocational nurse and patient navigator Stacy Mendez first went to visit Jane at her home, with the intention of getting her medical history, setting health goals, and putting an action plan in place. However, Jane was skeptical about the program and resistant to sharing her personal and medical information.
“When I first went to see Jane, she was in her pajamas, her home was dark and it seemed like she had been lying down. It took a while to get through to her – even after I described what the program could offer,” says Mendez.
After doing a depression screening, it was clear that Jane’s depression was a key barrier to getting her engaged in the program, says Mendez.
Eventually, Jane opened up and Mendez learned that she was supposed to follow a sliding scale method to monitor her blood sugar, but didn’t know how. She also learned that Jane wasn’t eating right and hadn’t had a diabetic foot exam.
Working with Mendez, Jane received critical health education, including the signs of infection, chronic disease management and medication adherence, the importance of logging blood sugar results, weight, diet and keeping follow up appointments with a Primary Care Physician (PCP). Jane made an appointment with her PCP, where she learned to use her glucose monitoring scale and was put on an anti-depressant. She also saw a podiatrist to learn proper foot care, and met with a dietician that provided counseling on how to eat properly to better manage her conditions. Mendez and Jane also discussed putting safety measures in place, such as a medical armband for diabetes and/or a Life Alert system, since she was living mostly alone, fairly far from a populated area.
“I looked forward to her weekly visits and learned quite a bit,” says Jane, who credits Mendez with much of the education she received during the course of the program.
A Measurable Improvement
Jane received navigation services for two months. During each visit, her blood glucose logs were reviewed, goal progress was assessed, and education about managing her conditions was reinforced. By the end of this time, Jane saw tremendous improvement in her blood sugar and blood pressure readings, and she had new confidence in her ability to care for herself.
Most impressive, and arguably most important, was the improvement in Jane’s depression. After seeing her PCP and beginning to take anti-depressants, Jane had renewed interest in activities and began to have hope.
Jane is now back to her daily routine, which includes creating quilts for graduates, newlyweds and babies at her church. She also drives to the grocery store, cooks and attends her weekly seniors group.
“The program got me back on my feet,” says Jane. “I feel so much better.”
Meeting Community Needs
Health is profoundly influenced by social factors such as housing, transportation, nutrition and personal safety as well as access to education and employment. PSJH is committed to developing community-based solutions in collaboration with community partners to address these social determinant challenges, which improve the overall health of our communities.
The Patient Navigation program was created in direct response to a regional community health needs assessment (CHNA), which identified health-related social needs (food insecurity, mental health, inability to afford medication, etc.) as one of the greatest unmet needs in the region. The program strategically addresses these community needs, one patient at a time. By thoroughly assessing each patient, providing needed education and access to resources, and preparing an action plan that helps patients understand what to do when they experience certain symptoms, patients are empowered to care for themselves and know what to do if they need help. This ensures patients are seeking treatment at the onset of critical symptoms, helping avoid unnecessary health events and Emergency Department (ED) visits.
Patients are referred to the program from partner organizations in the community, case managers, the ED, the Covenant Health medical group, or from another community benefit program. During 2018, the program served more than 300 patients in the greater Lubbock area.
The program was originally funded in 2012 by a federal grant. However, when that funding disbanded in October 2018, the navigation team sought community benefit funding to continue their important work in the community. Community Benefit contributions to the Patient Navigation Program were approximately $150,000 from October through December 2018, with more than $600,000 in Community Benefit funds allocated for 2019.
*Patient has given Providence St. Joseph Health permission to share her story, but the name has been changed to protect patient privacy.