How Patient Navigators Saved Thanksgiving

The afternoon before Thanksgiving, patient navigator Emma Villarreal completed a PArTNER post-discharge home visit with Myra*, a participant in the PArTNER program, who had been discharged from the hospital a few days before. Myra, age 75, was a shy widow with worried eyes and a warm smile. She welcomed the patient navigator into her sparingly furnished apartment, apologizing for the disarray and explaining that she had been unwell and unable to care for her home for a while. 

In a corner of the room was a small desk covered with children’s books, markers, and school supplies, as Myra was the legal guardian of her 9-year-old granddaughter, whose parents had died. The child was in the home during the visit, and appeared bright, helpful, well-spoken and well-mannered, despite the challenges faced by her family.

In the course of the PArTNER home visit, Emma asked Myra if she and her granddaughter would be celebrating Thanksgiving. Myra lowered her eyes and confessed, embarrassed, that she and her granddaughter barely had enough food to get by on a daily basis, and would not be able to prepare any kind of special dinner for Thanksgiving. She then showed the patient navigator her almost empty refrigerator and bare cupboard.

Emma knew that the listing for the food depository was current and the number accurate, because the listing had been obtained from Purple Binder.

Emma realized that food insecurity was a major concern for Myra, and an increased source of anxiety during a holiday. She had to act fast, as there was little time to find food for Myra and her granddaughter. Emma immediately consulted the participant’s PArTNER discharge plan, which included a customized list of social resources in the neighborhood. The contact information for the local food repository was there, and Emma called their line. She knew that the listing was current and the number accurate, because the listing for the repository had been obtained from Purple Binder.  

Emma Villareal, one of PArTNER’s patient navigators.

As Emma explained Myra’s circumstances to the food repository workers, they agreed to hold their last Thanksgiving chicken for Myra. They asked that the navigator come and pick up the food as soon as possible, as the repository would only remain open for 30 more minutes. Fortunately, the repository was just down the street; getting the list of social resources from Purple Binder had allowed the navigator to find the food bank nearest to the Myra’s home. 

Emma got to the food repository a few minutes later, and received the chicken and six bags of food that had been set aside for Myra. When Emma delivered the bags of food to Myra’s kitchen and started unpacking bread, cereal, fruits, canned vegetables, as well as the juice boxes and kid-friendly snacks provided by the repository for the child, Myra and her granddaughter could not believe their eyes. They were overwhelmed by the generosity of the food pantry and by the care they received from the navigator. Before Emma completed the home visit and left the home, Myra spontaneously called the PArTNER supervisor to express her gratitude and appreciation.

With the list of social resources from Purple Binder, the navigator was able to find the food depository nearest to the patient’s home.

Myra now knows how to access nutritious food in her community for herself and her granddaughter, if she needs it in the future. Furthermore, sixty days after Myra was discharged from the hospital, Myra has not needed to return to the hospital and, with a little help from the navigator to arrange for transportation, has been attending her medical appointments.

*Participant’s name and identifying details have been changed to protect privacy and confidentiality.

How PArTNER works with Purple Binder to help patients

What is PArTNER?

Part of the PArTNER team at the University of Illinois Hospital & Health Sciences System

PArTNER (PATient Navigator to rEduce Readmissions) is a clinical trial at University of Illinois Hospital & Health Sciences System, led by Jerry Krishnan and funded by a contract from the Patient Centered Outcomes Research Institute. The PArTNER study is designed to help the health system evaluate how community health workers serving as patient navigators can serve the needs of patients with limited socioeconomic resources.

“Ultimately, by allowing them to take better care of themselves, we aim to keep patients healthier and out of the hospital.” -Amelia Mutso, Project Manager with PArTNER

“PArTNER helps patients have a better transition from hospital to home. We identify and help remove barriers to care, and connect our patients with community resources,” says Amelia Mutso, PArTNER’s Project Manager. “We believe that a program with patient navigators, who are proactive lay patient advocates from the community, together with peer support, will increase social support, improve self-efficacy, and reduce anxiety in patients who are going home from the hospital. Ultimately, by allowing them to take better care of themselves, we aim to keep patients healthier and out of the hospital.”

Amelia Mutso, PArTNER’s project manager.

How does PArTNER work?

The PArTNER coordinator visits patients hospitalized at the University of Illinois Hospital for myocardial infarction, heart failure, exacerbation of chronic obstructive pulmonary disease (COPD), pneumonia, or sickle cell crisis. The coordinator explains to the patient what the PArTNER study is about, and asks whether they consent to join the trial. After enrollment, patients are randomized to either the intervention group or the usual care group.

How is Purple Binder an integral part of PArTNER?

Medical care on its own may not be enough to keep patients who are living with chronic disease healthy. According to the Center for Healthcare strategies, about fifty percent of preventable deaths are attributable to non-medical factors, such as social circumstances, environmental factors, and individual behaviors.*

Purple Binder helps PArTNER connect study participants with their non-medical needs- for instance, once Myra was connected with her local food bank, she and her granddaughter no longer had to go without adequate nutrition. Through partnership with Purple Binder, PArTNER navigators have access to curated resources and services, located in their participants’ communities. PArTNER navigators know that the information in Purple Binder is accurate and up-to-date. Furthermore, Purple Binder includes detailed and concrete information about how to access community resources, making it easy for navigators to explain to participants how to access the services they need themselves- further removing barriers to care, and ensuring that participants remain healthy and safe.

*A. Spencer, J. Lloyd, and T. McGinnis. “Using Medicaid Resources to Pay for Health-Related Supportive Services: Early Lessons,” The Center For Healthcare Strategies, Dec. 2015.

Photos by Michelle Kanaar.