Improving Patient Outcomes with a Warm Community Hand-Off

Circle of Care’s social work Care Navigators, left to right: Sherin Surenthiran (Mount Sinai Hospital), Maria Valle Perez (Rekai Centre Transitional Care Unit), Anna Siciliano (Independence at Home Community Outreach Team – SHS/UHN), Revital Shuster (Bridgepoint Active Healthcare), Patricia Wendy (Sinai Health System Academic Family Health Team – Vaughan)

Improving patient outcomes with a warm community hand-off

For many vulnerable patients, especially frail older adults with complex health and social issues, the risk of slipping through the cracks after a stay in hospital or a referral within the community is real. As a result, repeat visits to the emergency department or lengthy hospital readmissions are likely.

But when this same demographic of patients is supported by an interprofessional clinical team that includes a social worker from Circle of Care, Sinai Health’s system partner, a virtual safety net is cast into the community, leading to far better outcomes for patients, caregivers, and also the system as a whole. In fact, response to Circle of Care’s Social Work Care Navigators has been so positive that the role is now incorporated across five sites, including the most recent addition at Bridgepoint in July.

The primary role of the Care Navigator, says Natalie Zabolotsky, Circle of Care Social Work Practice Lead, is to identify community supports that will improve health and independence at home, and to help remove the barriers many patients and families come up against on their own. “The reality is that navigating the system for patients with complex needs can be incredibly overwhelming,” she says. “There could be waitlists, financial constraints, age restrictions, geographic boundaries, and lack of communication between providers. It’s not hard to see how people can get overwhelmed and give up,” says Zabolotsky.

That’s when the Care Navigator becomes a lifeline, not only in providing emotional support and guidance throughout a patient’s journey, but by unlocking essential access to care. Depending on a patient’s specific health needs and social circumstances, the Care Navigator and clinical team collaborate with the patient and family on a coordinated care plan that could include any combination of the following: community support services, home care, housing, financial aid, caregiver support, rehabilitative services, mental health services, and home-bound programs. Once initiated, the Care Navigator continues to follow patients back at home or in the community, ensuring a smooth transition and adjusting the plan as necessary.

For Sherin Surenthiran, Care Navigator at Mount Sinai Hospital, the ability to seamlessly follow up with clinicians on specific challenges or issues their patients might be facing at home, is a significant benefit to the partnership. “Being able to easily connect with the pharmacist to review medications, for example, or closing the loop on a particular patient, really highlights the importance of the continuum of care,” she says.

The Care Navigator role is also making a positive impact on ALC (Alternate Level of Care) hospital stays, visits to the emergency department and hospital readmissions. In the case of isolated seniors who have no family to advocate on the their behalf, the Care Navigator’s involvement allows inpatient social workers to discharge patients to a temporary respite location where the Care Navigator works with the patient to find suitable, permanent housing.

“Without the help of my Care Navigator, I would have ended up in a group home or nursing home, and I’m not ready for that yet,” said one patient who found herself homeless when a miscommunication during a recent hospital stay resulted in losing her apartment. Upon discharge, she moved on a to a six-week transitional care unit before moving into a permanent supportive housing unit for older adults. “It would have been extremely difficult to make this happen on my own. I really needed her and the reassurance that she gave me.”

Dr. Samir Sinha, Sinai Health System’s Director of Geriatrics says the commitment and expertise Care Navigators bring in helping people remain in the community, and out of hospitals and long-term care homes, is a testament to the value they bring to our already strained health-care system.

“In situations where complex social issues or medical conditions are at the heart of what is threatening people to stay healthy and independent in their own homes, Social Work Care Navigators are an integral solution,” he says. “Being able to count on a community expert who can help address social issues–like housing, caregiver burnout, and access to meals, transportation and counselling–is a tremendous asset to the rest of the clinical team.”

Sabrina Gaon, Senior Manager, Complex Care Transitions at Sinai Health System, agrees. “Partnering with the Care Navigator alleviates some of the concern the clinical team may feel about their patients managing at home. It’s a relief for them to know there’s a professional set of eyes out there, continuing to assess any risks and being able to communicate to the team if anything changes.”