An interview with Rokhaya Sarr and Marisol Rivera, CHCA’s Care Navigators.
Note: We have condensed both Rokhaya and Marisol’s answers to give you a concise overview of the role of a CHCA Care Navigator
Describe your role as a Care Navigator
In our role as Cooperative Home Care Associates (CHCA) Care Navigators, we work diligently to help manage our client’s health. Our overall goal is for our clients to remain out of the hospitals, by connecting regularly with them to ensure that they maintain their medical appointments and follow doctors’ orders to improve health outcomes.
We communicate consistently with clients, their families’ members, their doctors, and of course health plans to ensure that everyone is on the same page sustaining and monitoring the client’s health condition and progress.
How do Care Navigators assist the client in maintaining their medical appointments? Why is this task part of your role?
As Care Navigators, we frequently check in with clients to ask when their next visit to their doctor is, and we promote the importance of not missing their appointments through conversations with the client, their family members, and the worker. Caregivers are also involved in promoting the importance of wellness and routine medical visits. For those clients who may have an illness that prevents them from leaving the house, we help support the client in scheduling a physician to conduct a house visit. Normally this is done for clients that have dementia, Alzheimer’s, limited physical mobility, without a working wheelchair, or they have no Hoyer lift to get them out of bed.
These tasks are part of our role to help keep clients out of the hospital, support them to live independently in their homes, and assist them in maintaining their health and wellness.
Do Care Navigators follow up with clients once they are discharged from a hospital stay?
Yes, we follow up with the client's post-hospitalization. We are eager to learn how the client is doing and if there are any changes to their medications. We inquire if the client was able to pick up their medication because we knew that it is important for the client to follow the doctors’ orders. It is also important to know if any new medication prescribed has a potential side effect or conflict with current medication intake. In addition, we ask the client if the doctor has prescribed specific equipment, we want to ensure that the client has all the necessary medication and equipment to help them start feeling better and keep them safe at home.
How do you become aware of health changes in the client's condition?
We become aware of the client’s health changes through the observations of our Home Care Workers, who report back to our office. Once we learn of a change in condition, we immediately call the client to determine if there is a need to contact their doctor or visit urgent care. In addition, we notify the client’s healthcare team with the goal of having the client receive medical attention as soon as possible. We have to advocate for our clients to ensure that the doctor’s office accommodates the client. In some cases, depending on the situation, we may instruct the worker to call 911.
Why is it important to report changes in the client's health condition to the healthcare team?
It is important to report changes in the client’s health condition to their healthcare team so everyone is aware and can help the client to have the best health and living conditions.
Do you help connect clients to resources they may need in their community?
Yes, often, we call the health plan, on behalf of clients, to schedule transportation to and from the client’s medical appointments. We also notify the client’s Case Manager if the client does not have food in their home. The goal is to connect the clients with free food programs such as the Meals on Wheels program or local food pantries.
How do you orient replacement workers?
When Home Care workers take vacation or a leave of absence, we conduct telephone orientations for replacement workers to ensure that the replacement Home Care Worker is familiar with the client’s health condition. For example, it is important for a replacement worker to know if the client has vision problems or uses a walker, so the worker ensures all paths are clear in the client’s home. We are committed to providing our workers with vital information that will help keep the client safe in their home.
What other tasks does the Care Navigator perform?
We confirm the client's admission date to the hospital, follow up with recommendations from our registered nurses after they have conducted home visits, and we contact clients to inquire about their interest in immunizations and dental visits to help schedule appointments.
What do you think is the most challenging aspect of supporting a client in your role as a Care Navigator? How do you overcome these challenges?
The most challenging aspect of supporting a client in our role as a Care Navigator is when a client is facing a serious and debilitating health condition, and it is incredibly difficult for them to manage and accept their change in condition. Clients who have lived independently and have been self-sufficient may find it challenging to come to terms with the fact that they need others to assist them. As their Care Navigator, it is important to continue to communicate our role in helping them navigate through the healthcare system and promote the importance of maintaining their appointments and taking their prescribed medications. It is also instrumental to be patient when supporting clients and reassure them that they are not alone.
Why is the Care Navigator an essential role in the agency?
The Care Navigator role is essential in our organization because we support our clients in understanding the importance of following through with their medical appointments and ensuring they have their medications to help them manage health conditions. We do this to help the client improve their quality of life and in some cases may even be lifesaving. We are focused on helping the client to age safely at home.
What makes this job rewarding?
What makes this job most rewarding is when we can guide our clients in making choices that benefit their health condition. When clients avoid hospitalizations because we were able to impact their outcomes, they are appreciative and express their gratitude, that is the best reward for us.