Recieving Care through the Patient Navigator Program at Saint Francis
By Jessica Escober and TLHIP
The Emergency Department at Saint Francis Memorial Hospital is often the primary source of care for many low-income and uninsured individuals in San Francisco. As a community hospital, Saint Francis cares for a high proportion of Medi-Cal and Medicare patients. Many of these patients face a complex web of challenges and barriers to accessing primary care including legal status, lack of a medical home, gaps in insurance, ongoing financial challenges, homelessness, among others.
However, research indicates that primary care (like clinics), culturally sensitive medical care, and better care coordination can lead to improvements in health and well-being for individuals and can reduce hospital readmission rates overall. For these reasons, Saint Francis Memorial Hospital partnered with Tenderloin Health Services, a medical home to over 3,000 patients in the heart of the neighboring Tenderloin community, since 2013.
The Tenderloin has a significantly higher preventable ER visit rate than San Francisco overall.
What began as a grant from Saint Francis Foundation to employ a transition coordinator, later evolved into the current day Community Navigator Program: a community-based intervention designed to improve health by reducing barriers to primary care. The Navigator Program employs a staff member from Tenderloin Health Services who is stationed in the Emergency Department at Saint Francis four days a week. Their job is to help provide some relief from financial and access barriers, fears, distrust, emotional and behavioral issues that may arise and have often been left unsolved.
What is a Patient Navigator?
Fortunately for Saint Francis, the Patient Navigator, Monique Randolph, has extensive work experience, a well-rounded background and a personal experience she draws upon that make her an amazing asset to the team at Saint Francis.
As the Patient Navigator, Monique works closely with hospital case managers, social workers, financial counseling departments, as well as other medical staff to assist patients during their transition out of the hospital setting and into an appropriate care provider or medical home – a location that will be well-suited for ongoing medical treatment and support. Patients frequently include Tenderloin residents, Healthy San Francisco participants, and those with public insurance like Medi-Cal and Medicare, who are most at risk for avoidable readmission after discharge.
Monique's main focus is to develop relationships with clinics and to schedule follow-up primary care and/or specialty care appointments for eligible patients. Specialty care appointments could be scheduled with Sports Medicine, Urology, Endocrinology, Psychology/Therapy and more.
Monique Randolph started working at Saint Francis Memorial Hospital three years ago in 2015. However, her career in healthcare and social services started much earlier. In the 1990s, Randolph was certified in HIV education and became an HIV counselor while she was in college. She was also a group home counselor for adolescents.
Her experiences caring for the elderly, adolescents, individuals struggling with addiction, and with individuals living with HIV, give Monique the unique ability to see past patients’ differences and understand where they are in their lives and the needs they deem important at the moment. “When are we going to start trying to HEAL people? It’s not about whether their homeless, Black, Latino, Asian, or whatever. Everyone should be respected and treated as human beings,” Monique tells me.
Growing up in Oakland, California - substance abuse, the broken justice system and the crack epidemic were the growing pains of her time. Stereotypes about addiction were abundant. Nowadays, Monique draws from these experiences and understands addiction as a survival mechanism, similar to gambling and alcohol consumption.
Randolph’s grandmother was the thirteenth child out of a flock of sixteen children. Her grandmother herself had ten children, three girls, and seven boys. Coming from a large family, Monique’s upbringing was one about assisting and uplifting one another. Such sentiments are noticeable with whomever she interacts. “I’m not afraid of what people look like. People don’t wake up wanting to be homeless or on drugs. I want to make a difference by helping them find a balance,” Monique says.
Practices for Success as a Patient Navigator
Monique’s success is driven by her ability to connect with people. As a Patient Navigator, Monique practices Motivational Interviewing and trauma-informed care. Motivational Interviewing is a practice guided by five principles which are: (1) expressing and showing empathy towards clients through reflective listening, (2) developing discrepancy between clients’ goals and their current behavior, (3) avoiding argument and direct confrontation, (4) adjusting to client resistance rather than opposing it directly, and (5) supporting self-efficacy and optimism” (Miller and Rollnick, 1991).
Motivational Interviewing is not a way of tricking people into changing; it is a way of activating their own motivation and resources for change." - Miller and Rollnick, 2013
Monique also draws from trauma-informed care practices: acknowledging the trauma experienced by individuals and recognizing the various reactions and coping mechanisms an individual may have developed in order to better understand and support a patient in a clinical setting. Trauma-informed care can facilitate patient engagement, which is essential for improving health outcomes.
As a Patient Navigator, Monique is all about introducing herself and her role, asking questions, and establishing good relationships with her patients. Her philosophy includes putting herself in the shoes of the people in the streets who are typically judged by others and leading with compassion. She does not try to tell patients what to do. Instead, she gives them suggestions, allowing them the opportunity to grow. “I try to motivate them to look at something a bit differently, or at least to have a conversation about it,” she tells me.
At Tenderloin Health Services, where Monique works once a week, I met a co-worker of Monique who had a lot to say about her. “She’s the most wonderful person in the world. She talks to people at their level and they start responding to her. She has a special bond with people,” she told me.
The results thus far have demonstrated a strengthening of the connection to primary care clinics in the neighborhood. Out of the 733 encounters/persons served from July 2017 to June 2018, 553 or 75% of appointments were set-up across four clinics which are: Tenderloin Health Services, Tom Waddell Health Clinic, Curry Senior Center Clinic and St. Anthony’s Health Clinic, with an overall 68% show rate.
As can be seen, the number of encounters in the ER of Saint Francis has significantly lowered in 2017-2018, compared to prior measurement periods. Moreover, the graphs on the side give a detailed breakdown of appointments made, show rate count, and show rate percentage by clinics. In both 2016-2017 and 2017-2018, the show rate for primary care appointments was highest at St. Anthony's Clinic, followed by Curry Senior Center, Tenderloin Health Services and Tom Waddell Clinic
Since the start of the Community Navigator Program, a few lessons have been learned in terms of best practices and ways to improve patients’ health and wellbeing. Those lessons include the need to have a better understanding of the multiple barriers and constraints that patients face in order to attend their appointments and/or use resources and services. That is why Monique plays an important role in providing support and making sure patients are able to take care of themselves even after they step out of the hospital doors.
In addition, a Navigator with deep connections to the community they serve and with public service experience prove to be most effective in their role as care coordination concierges focused on patient well-being. Nonetheless, the collaboration between Emergency Department staff, Patient Navigator, community clinics, and other service providers is essential and must be continued, especially for patients with multiple complex chronic conditions.
Still, challenges persist. Data privacy concerns and lack of a universal patient medical record can impede successful coordination. However, that can be overcome through strong patient engagement, as mentioned before, to ensure successful outcomes for those with whom Monique interacts.
Strengthening Partnerships with Tenderloin Health Services
"You never know when you are going to need help. How would you want people to help YOU?"
Monique Randolph strives to utilize her resources, networks, and outgoing demeanor to better assist everyone who comes to the Emergency Department at Saint Francis. Monique’s role model to follow in order to accomplish this goal is her mother, a nurse. As a young child, Monique remembers visiting her mother at work and having people tell her that she had a “beautiful mom with a kind and helpful spirit.”
Monique wishes to exhibit those qualities herself when she provides care coordination in order to see the community around her change and thrive. “You never know when you are going to need help. How would you want people to help YOU?” Monique said to me. In her role as a Patient Navigator, Monique Randolph can too, be described as a kind and helpful spirit. And it is that heart that continues to be the source of success for the Patient Navigator Program at Saint Francis.
Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive Behavior. New York: Guilford Press, 1991
Tenderloin Health Improvement Partnership (TLHIP) is a multi-sector collective impact partnership committed to improving health and well-being in the Tenderloin by aligning priorities, resources and activities to create pathways to health for residents.
Led by the Saint Francis Foundation and Saint Francis Memorial Hospital, TLHIP provides a framework to better coordinate between institutions, co-create solutions and deliver a deeper impact. Since 2014, TLHIP has organized a strong, multi-sector partnership and funded innovative, community-based solutions to create a healthy, vibrant, and safe neighborhood and end the cycle of poor health.