Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter. Client Navigator - A position funded through Home Care and the Saskatchewan Ministry of Health that provides you with a single contact for persons needing to use community based services in the Cypress Health Region. The Client Navigator is a nursing professional to help you arrange for care and discharge planning. Better Health Marilyn Krause

1. Client Navigator, Cypress Health Region
Marilyn Krause
This Session is sponsored by:

2. Marilyn Krause RN

4. A Ministry and Home Care
funded temporary position to
“pull” surgical patients back
to the Cypress Health Region
from Tertiary Centers as part
of the Surgical Initiative.

5. Acute LTC Program
Home care

6. Urban
Rural
CHR
Customers

7. CN
All Discharge
planning teams
Rehab
Home Care
+
EMS-MHS
Facilities

8. Tertiary
patient
CHR-Urban
LTC
Acute
CHR-Rural Integrated

9. CYPRESS
REGIONAL
HOSPITAL
(CRH)
Registration
How are
they
involved??

11. THEN
WHAT
???

12.  Social Workers
 Rehab-PT/OT (which
Include MHS-Mobile
Health Services in rural
sites.)
 Case Managers
 Home Care Nurses
 EMS-Falls Prevention
& home safety checks

14. What is this committee for?
Patients are assessed and presented for program
beds (convalescence) or LTC placement. Tertiary
patients could be transferred for these reasons.
Who is on the committee?
Director, Home Care Manager -Chair, Client
Navigator, Case Manager.
How are they prioritized?
Based on need, assessment tools and chronological
order. Patient is given the most appropriate bed in
the region by the Client Navigator. Client is
navigated in and through the system.

15. Discharge Planning includes the Patient and their Families.
Discharge Planning Teams

17.  Procura-client information/dated notes
 Wincis-bed availability
 LTC Database-bed flow
 CN Citrix program-Tertiary transfers to CHR
 MDS-Assessment information for placement
 Sharepoint-Hoshin, Home care, CAPC,
information sharing with colleagues
 Mobile Health Services (MHS)-Citrix for Falls
tracking.
 Reports can be generated from all the above
programs for Statistics and Quality.

18.  To be part of the Discharge Planning committee
and discharge teams to standardize discharges.
 Review readmissions-Are patients in the
appropriate beds for recovery?
 EMR-protect patient’s confidentiality but also
communicate and share information in the circle
of care.
 Assist patients to navigate through the health
care “maze” reducing hazards/barriers and
burdens for the patient and their family.
 Patient centered v.s. Process centered.

19.  It is an honor to be able to speak to the efforts, support and compassion that I
was provided when looking to have my mother transferred to Swift Current from
Saskatoon. We had moved mom up to Saskatoon when it became apparent that
she could no longer support herself and required help with food, medications, etc.
She lived in a private level 1 care home for around 4 years. In December, 2012 she
got quite sick and was admitted to St. Paul’s Hospital in Saskatoon where she
spent about three weeks recovering. When she was finally stabilized, our family
felt it was best to have her transferred down to Swift Current as this was her
hometown and she was requiring level 3-4 care, which was available in Swift
Current. At that time, I approached Marilyn to see if this was possible and how I
would even begin to make it happen. It was then I truly understood not only the
scope of work of a Client Navigator, but also the exceptional way that Marilyn was
able to clearly explain the process and be there with me every step of the way.
Within a matter of days, I had my mother back in Swift Current, first in our
hospital and then into the Prairie Pioneer Lodge where she is getting the care she
requires and is being treated like a queen! The position of Client Navigator and
Marilyn Krause in particular is a huge benefit to our Region and I can’t thank her
enough for the work she puts in!
Grant Browne Medical Affairs Coordinator Cypress Health Region

20.  In July 2012 my father had surgery in Saskatoon. Prior to his surgery we had made contact with
Marilyn Krause, Client Navigator to determine how we could have him back in Swift Current as soon
after surgery as possible, and what was available to support my parents, and our family in his recovery.
Marilyn was able to arrange for him to be admitted to a program bed at the Palliser Regional Care
Center for about a week of rehab and recovery, before he returned home. Marilyn’s position of Client
“Navigator” is exactly that – she was our navigator thru the process – she offered information, options,
advise, people to contact, support and encouragement. We had a few surprises with some
complications after surgery, which delayed his return slightly, and some “not so cooperative
circumstances with the Saskatoon physician and hospital”, but with Marilyn’s help we were able to have
him transferred by ambulance and he very much enjoyed the time he spent in the Palliser with that
extra recovery time, and our whole family was more comfortable that he was “ready to go home”,
which is about 25 miles outside of the city.
 Even though I work in the Health Care system, and have some knowledge of how to access the
services provided, I think the Client Navigator position is extremely valuable for patients and their
families. Marilyn does an excellent job in this role, and my parents and family were very happy to have
her assistance and expertise.
 Shelley Dawson-Briere, Senior Labour Relations Consultant-CHR

21. The Client Navigator is the link between all
health regions and disciplines in the
communities we serve.

22. Client Navigator

23. Thank you for your attention.
**Remember to have a great day!!
The End