Client Navigator, Cypress Health Region Marilyn Krause

This Session is sponsored by:

Marilyn Krause RN

A Ministry and Home Care funded temporary position to “pull” surgical patients back to the Cypress Health Region from Tertiary Centers as part of the Surgical Initiative.

Acute LTC Program

Home care

Urban

Rural

CHR

Customers

CN

All Discharge

planning teams

Rehab

Home Care

+

EMS-MHS

Facilities

Tertiary

patient

CHR-Urban

LTC

Acute

CHR-Rural Integrated

CYPRESS REGIONAL HOSPITAL (CRH) Registration

How are they involved??

THEN WHAT

???

Social Workers Rehab-PT/OT (which Include MHS-Mobile Health Services in rural sites.)

Case Managers Home Care Nurses EMS-Falls Prevention & home safety checks

What is this committee for? Patients are assessed and presented for program

beds (convalescence) or LTC placement. Tertiary patients could be transferred for these reasons.

Who is on the committee? Director, Home Care Manager -Chair, Client

Navigator, Case Manager. How are they prioritized? Based on need, assessment tools and chronological

order. Patient is given the most appropriate bed in the region by the Client Navigator. Client is navigated in and through the system.

Discharge Planning includes the Patient and their Families.

Discharge Planning Teams

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 Falls

tracking. Reports can be generated from all the above

programs for Statistics and Quality.

To be part of the Discharge Planning committee and discharge teams to standardize discharges.

Review readmissions-Are patients in the appropriate beds for recovery?

EMR-protect patient’s confidentiality but also communicate and share information in the circle of care.

Assist patients to navigate through the health care “maze” reducing hazards/barriers and burdens for the patient and their family.

Patient centered v.s. Process centered.

It is an honor to be able to speak to the efforts, support and compassion that I was provided when looking to have my mother transferred to Swift Current from Saskatoon. We had moved mom up to Saskatoon when it became apparent that she 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 she got quite sick and was admitted to St. Paul’s Hospital in Saskatoon where she spent about three weeks recovering. When she was finally stabilized, our family felt it was best to have her transferred down to Swift Current as this was her hometown and she was requiring level 3-4 care, which was available in Swift Current. At that time, I approached Marilyn to see if this was possible and how I would even begin to make it happen. It was then I truly understood not only the scope of work of a Client Navigator, but also the exceptional way that Marilyn was able 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 our hospital and then into the Prairie Pioneer Lodge where she is getting the care she requires and is being treated like a queen! The position of Client Navigator and Marilyn Krause in particular is a huge benefit to our Region and I can’t thank her enough for the work she puts in! Grant Browne Medical Affairs Coordinator Cypress Health Region

In July 2012 my father had surgery in Saskatoon. Prior to his surgery we had made contact with Marilyn Krause, Client Navigator to determine how we could have him back in Swift Current as soon after 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 Care Center 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 some complications after surgery, which delayed his return slightly, and some “not so cooperative circumstances with the Saskatoon physician and hospital”, but with Marilyn’s help we were able to have him transferred by ambulance and he very much enjoyed the time he spent in the Palliser with that extra 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 the services provided, I think the Client Navigator position is extremely valuable for patients and their families. Marilyn does an excellent job in this role, and my parents and family were very happy to have her assistance and expertise.

Shelley Dawson-Briere, Senior Labour Relations Consultant-CHR

The Client Navigator is the link between all health regions and disciplines in the

communities we serve.

Client Navigator

Thank you for your attention.

**Remember to have a great day!! The End