Programming Connection

Chronic Health Navigation Program 

ASK Wellness Centre
Kamloops and Merritt, British Columbia
2014

How Does the Program Work?

The Chronic Health Navigation Program is available to people living in ASK Wellness Centre housing and to people living with HIV or hepatitis C in Kamloops and surrounding areas. Most people referred to the Chronic Health Navigation Program come to the program in crisis, when they are experiencing an acute need for extra support. Some are newly diagnosed with HIV (or another chronic illness); others have been living with untreated HIV, hepatitis C or other chronic illnesses (e.g., epilepsy, Parkinson’s, cancer, chronic obstructive pulmonary disorder) for years and their health is deteriorating. About 80 percent of the program’s clients live with HIV or hepatitis C.

The role of health navigators is to educate, guide and advocate for clients along their health journey. They support clients to access housing, healthcare and additional financial assistance to improve their health and well-being.

ASK Wellness Centre has two full-time staff positions for navigators. Unlike Peer Navigation Services in Vancouver and the Peer-to-Peer Program in Regina, ASK Wellness does not exclusively hire people living with HIV to provide navigation. It selects individuals who demonstrate an understanding of the barriers and challenges marginalized people living with a chronic illness (including HIV and hepatitis C) may face and an ability to build on the strengths and abilities of clients to achieve better health outcomes. Health navigators in this program do not necessarily have personal experience with these illnesses.

Housing-first model

ASK Wellness Centre uses a housing-first model in all its work in Kamloops. This model is based on the idea that clients who are homeless or at risk of homelessness must be stabilized in housing before they can tackle more complex issues such as their health. ASK Wellness Centre (as of January 2014) manages 130 housing units in Kamloops, including units in single room occupancy hotels, apartments and townhouses. ASK Wellness Centre’s direct management of these units facilitates access to housing for those who are most marginalized.

Although housing is a top priority, navigators also work with clients to take care of the psychosocial and healthcare needs clients identify as critical. They do this by working with pharmacists, street nurses and outreach workers to minimize the delays in people receiving the care they need.

Using a self-management approach to health navigation

The Chronic Health Navigation Program uses a self-management approach in its work. Clients are encouraged to take on as much of their own care as they can manage, and they have to demonstrate that they are committed to becoming more independent as they achieve the goals of their care plan. What this actually entails for each client is different. For one client this might mean applying for additional social assistance without the help of a navigator; for another, it might mean making one appointment with a counsellor once a week without the help of a navigator.

For this approach to be effective, the health navigator and the client must have a trusting relationship. For the most part, health navigators work with people who may distrust authority figures and healthcare providers. A self-management approach, which may feel to some like “tough love,” may trigger some clients to disengage if used too early in the client-health navigator relationship. Health navigators work over months and years to develop a trusting relationship that allows them to use a self-management approach without alienating clients.

Using a self-management approach in health navigation builds confidence in clients. Many clients use the program when they are at their most vulnerable, when they are experiencing difficulty accessing healthcare, financial support and housing services. Over time, while working with a health navigator, clients learn how to navigate health and social services independently. When their navigator observes and encourages their efforts, they gain the confidence to become even more independent.

Referrals

Many of the referrals to the program come from ASK Wellness Centre’s housing intake workers. Intake workers have integrated the offer of chronic health navigation services into their intake processes for new housing applicants. New residents at housing projects affiliated with ASK Wellness Centre, such as Crossroads Inn and Henry Leland House, where the intake process is different, have meetings set up with a health navigator to go over the services they offer and ensure that new residents’ health needs are being met.

Referrals for people living with HIV and hepatitis C and who live in the community come through a variety of sources, including the Ministry of Social Development and Social Innovation, Royal Inland Hospital, Kamloops Regional Correction Centre, community-based agencies, Round Lake Treatment Centre, public health staff and other healthcare providers in Kamloops and the surrounding areas.

Intake

When a potential client is referred to the Chronic Health Navigation Program, the two health navigators determine which one of them is the best fit for the client’s needs. Typically, the navigators divide clients by gender, with the male navigator taking men and the female navigator taking women. The female navigator also takes on some male clients because there are more men enrolled in the program than women. This gendered division of clients is done to provide female clients with a navigator who can more comfortably help address health issues that are specific to women. As much as possible, men who say they would prefer to work with a man are paired with the male navigator.

Once a prospective client is assigned a health navigator, the health navigator sets up a meeting with them. Together, the health navigator and the client complete an intake form (available in the Program Materials section of the case study). Space is provided on the form for the client and the navigator to discuss and record goals and care planning.

A client’s first six months

Clients of the Chronic Health Navigation Program are usually referred to the program with acute healthcare needs. Using a housing-first model, health navigators work intensively with clients to provide housing if they are homeless or at risk of homelessness. While a client’s housing is stabilized, health navigators help clients to make and attend healthcare appointments to diagnose and treat any health issues they face. HIV infection, complications from hepatitis C, chronic pulmonary obstruction disorder and cancer are the most common health problems clients of the program live with.

During the first six months, clients are in weekly contact with their health navigators and the health navigator will get to know the client and their history. This helps the health navigator support the client to develop a tailored set of goals for improving their health and independence. These are usually based on a healthcare provider’s recommendations. This intensive engagement, where a health navigator is a constant and reliable support to the client, builds trust between them and provides the foundation for a more long-term relationship.

Once a client’s immediate housing, health and food security issues are stabilized, the client and the health navigator work together to achieve more long-term goals for the client’s health and well-being. Each client’s goals are different; they can range from getting new dentures so a client can go back to work to a client living with HIV achieving an undetectable viral load.

Health navigator’s role

The health navigator’s role is to provide education, support and guidance to clients, tailored to the needs of each client. This includes assessing risk factors for HIV and hepatitis infection, providing harm reduction services and referrals for mental health and addictions services, facilitating referrals to primary healthcare providers, developing a support plan for medication adherence and accompanying clients to appointments.

Health navigators also advocate for their clients to break down barriers that may exist as their clients try to obtain health and social services. Health navigators work to re-engage both client and service provider in the client’s care, which may have been neglected for years. For some clients this may mean the health navigator facilitates appointments with healthcare providers, and for others this may mean the health navigator advocates for them with the Ministry of Social Development and Social Innovation or the Canada Pension Plan.

Re-engaging clients in their own healthcare also involves developing clients’ capacity to make and keep appointments and ask questions of their providers, skills that are key to improving health outcomes. Health navigators do this by accompanying clients to appointments in Kamloops or Vancouver to provide support, setting up appointments with pharmacists when new medications are prescribed, and coaching clients before appointments on how to ask questions of their healthcare providers. Over time, health navigators have observed clients develop the confidence to make appointments and see their healthcare providers more independently as a result of this type of support.

Typically, health navigators work with clients to identify community services and community members that might act as additional supports so that the health navigator is not the only person involved in a client’s care. This helps the client build a support network and makes them less dependent on their health navigator.

Ongoing client engagement

The reliable support of their health navigator in the first six months of a client’s involvement with the Chronic Health Navigation Program goes a long way to building strong long-term relationships between clients and navigators. This is key for most of the Chronic Health Navigation Program’s clients because they are marginalized people who live with chronic illnesses and will require, in some form, support for their whole lives. Health navigators never close a file on a client. Clients are welcome to use the program whenever they need it.

Most clients have periods of intensive engagement with their health navigator as a result of their street involvement and/or their chronic illness; these periods are followed by times of less intensive support. Aside from the initial six months, during which most clients receive intensive support from a health navigator, clients tend to seek more support during the first few months of diagnosis and treatment for HIV, hepatitis C, cancer or other chronic illnesses or when they experience a personal crisis.

Outside of periods in which they require intensive support, most clients maintain an ongoing relationship with their navigator and check in on a drop-in basis. When health navigators have not heard from a specific client in a few months, they follow up with them over the phone or in person.

Periodic client review

For all clients, periodic reviews take place—typically twice a year—with the health navigator connecting with clients during scheduled appointments or when they drop in. At these sessions the peer navigator and client review the personal care plan that was developed during the intake process and discuss what has been achieved to date, what is still left to accomplish and any other goals the client has identified.

This review allows the client and the health navigator to continue to work toward the client’s goals and to identify new goals. This usually requires that the health navigator work with the client to set up additional appointments with social service and healthcare providers. For both the client and the health navigator, periodic reviews provide some structure to their relationship.

Linkage to other health navigation services

Although Kamloops is a larger centre in the Interior of British Columbia, many specialist appointments, especially for people living with HIV, take place in Vancouver. In some instances, health navigators will accompany clients to Vancouver, but for those clients who are more independent and who travel to Vancouver on their own, the ASK Wellness Centre navigators refer clients to the Peer Navigation Services of Positive Living BC (PLBC).

This collaboration has allowed ASK Wellness Centre to extend the reach of its support at the same time as it reduces costs. Travelling to Vancouver for medical care can be a significant barrier for many clients. The city may be unfamiliar to them or may be triggering for clients with addictions who once lived there. Being able to see a peer navigator in Vancouver provides added support at what may be a difficult juncture in each client’s care. Overall, this collaboration improves linkage to and retention in care for many ASK Wellness Centre clients.

As an additional way to reduce barriers for clients, ASK Wellness Centre is currently exploring the feasibility of using TeleHealth services to link clients to specialists on a regular basis without the need for extensive travel to Vancouver and Kelowna.

Health navigation suites

Since 2011, the Chronic Health Navigation Program has set aside two supportive housing units for its clients. The suites, which are only a few blocks from the ASK Wellness Centre office in Kamloops, are designated for individuals living with HIV or hepatitis C who have significant healthcare challenges.

Originally, the suites were designated for people with complex healthcare needs who could benefit from acute support and having somewhere to live as they stabilized their health (street-involved people living with HIV who also had cancer, for example). The units are offered with a significant subsidy for rent, and the health navigators work closely with appropriate community services (for example, nursing, physiotherapy) that can offer in-home service.

Initially, the suites were offered to clients for two years. It was assumed the client’s health would be stable enough after two years for them to move to other units within ASK Wellness Centre’s housing projects or into market-rent suites in the community. In practice, the clients who have lived in these suites have usually needed such significant supports in the long term that transition to more independent living would not be recommended.

Thus, the Chronic Health Navigation Program no longer has a two-year limit on residence in these suites. Clients who need permanent long-term support are transitioned to long-term care facilities on a timeline that makes sense for the client. Clients who are reaching the end of their lives are allowed to remain in their suites as long as the care they receive there is adequate.

Health navigation in Merritt

In addition to the two health navigators in Kamloops, ASK Wellness Centre has a health navigator in Merritt, a city of 7,000 people 85 kilometres southwest of Kamloops. This navigator also serves clients in the surrounding rural area. Health navigation clients in this area are almost exclusively street-involved people needing support during a crisis. Unlike the program in Kamloops where clients are housed either before or at the same time they are assigned a navigator, the Merritt program does not require that clients have housing before being assigned a health navigator because there are fewer subsidized housing units available in Merritt.

The lack of a requirement that clients be housed makes it challenging for health navigators to work with clients in Merritt, and the interaction between the client and health navigator is almost always only during periods of acute need. Clients typically disengage after their acute need has been met and return only during another moment of crisis. For most clients, long-term care planning can seldom take place, although files on clients are never closed.

This model requires flexibility on the part of the navigator so that they can help their clients to achieve their immediate and critical goals. These goals can include support to get to specialist appointments in Kamloops or Vancouver or to seek assistance from other social services. Achieving them starts a relationship with the navigator that can last for years. Most new clients are referred to the program through other clients, which suggests that this model appeals to the population.