Care Navigation for Seniors in Erie

This article was first published in Millcreek In Community Magazine.

Facing a health crisis such as a stroke, emergency surgery or cancer diagnosis is a frightening and challenging journey. Imagine the burden that would be lifted if you had an advocate to help you handle all of the bewildering details that come with figuring out insurance coverage, treatment and available resources.

Meet the care navigator. A care navigator has two primary functions:

  • First, they help remove challenges patients face in accessing or receiving treatment, including communicating with insurers and providers.
  • Second, they make patients aware of and anticipate additional resources that could be helpful in their treatment.

A clear way through a complex system
Care navigation is a term that has been gaining attention as insurers have reduced the length of time they will cover a hospital stay and look to partner with health care providers who achieve better patient outcomes and lower rates of relapses and re-hospitalizations. To accomplish this requires greater communication and follow-up between various care providers, and making sure the patient has access to services such as transportation and home care. It’s a task that is time-consuming and too often, confusing.

At Springhill, care navigation begins the moment a new resident or short-term, rehabilitative patient walks through our door. For older adults, this service is of even greater importance. Often since they are working with multiple care providers and may have several chronic health conditions. Further, they may not have a spouse or adult child who is on hand to advocate for them through a health crisis.

Understanding the person
Springhill’s Care Navigation team helps guide residents according to their needs and prognosis with a focus on the total person. The service begins with an introductory meeting arranged between the new resident and the Springhill nurse. Understanding a resident’s health history, functional abilities and limits, as well as their expectations and lifestyle helps the team anticipate and plan for challenges.

When a resident faces a health issue, they help manage the resident’s care across the entire continuum – acute care, rehabilitation and therapy, home health and home care – in partnership with their respective physician. Their goal is to gain access to all the resources that can help that person return to their normal, independent life.

This is accomplished through weekly meetings between key members of Springhill’s staff – nurses, social workers, wellness, administrators and other teams such as housekeeping. They review resident challenges and discuss how residents who have been hospitalized or are receiving post-acute care are transitioning back to the community.

Confidence that care is correct
Joy McGaughran is the daughter of a Springhill resident who has experienced care navigation for a variety of health issues over the years.

“A recurring part of having an aging parent is how quickly unexpected health issues can come up,” Joy says. She recalls returning home after her mother had been released from the hospital following back surgery “utterly exhausted but with such confidence.”

As a long-distance, adult child, trying to figure out what health services are needed and how to get those services for a parent is “so scary,” Joy says. “Care navigation is better than a security blanket.”

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