Partnering With Patients to Overcome Everyday Obstacles

Date
August 28, 2012
August 19, 2019
Translating local innovation into statewide policy: Lessons from a medications for addiction treatment (MAT) prior authorization pilot in Camden, New Jersey
In this brief, we outline our prior authorization pilot program and our work with partners to translate the pilot into successful statewide policy.
Natasha Dravid and Alex Staropoli
August 19, 2019
Camden residents identify barriers to health in their neighborhoods
Members of organizations that have participated in our Faith in Prevention program conducted a health assessment of their Camden neighborhoods.
Whitney Buchmann
Camden Coalition staff and Community Advisory Committee members participate at the Housing and Community Development Network of New Jersey’s Annual Legislative Day at New Jersey State House
July 18, 2019
Camden Coalition joins the call to fully fund the Affordable Housing Trust Fund
To help secure FY2020 funding for the Affordable Housing Trust Fund, CAC members took part in HCDNNJ's Annual Legislative Day at the NJ State House.
Whitney Buchmann
July 16, 2019
From siloed systems to ecosystem: The evolution of the Camden Coalition’s complex care model
In this four-part series, we describe the phases of our care model as we addressed challenges and tested new solutions.
Kathleen Noonan and Kelly Craig
July 15, 2019
Graduates of Interfaith Homeless Outreach Council program reflect on their fresh start
Now in its 28th year, the Interfaith Homeless Outreach Council — or IHOC — has transformed countless lives.
Bill Nice
Camden Coalition care team member helps patient fill medication box.
July 11, 2019
Bringing it home: The shift in where healthcare is delivered
In this blog post for JAMA Forum, Lauran Hardin and Diana Mason write about two new opportunities to incentivize innovative complex care models.
Lauran Hardin and Diana Mason

By Julia Childers, Health Coach

Every morning as I report to Project H.O.P.E. and walk through the side door of the health center, I try to focus on how I can meet my patients where they are—not where I want them to be or on the terms that work at other primary care offices.

Project H.O.P.E. is a Federally Qualified Health Center that sees a majority of patients who are homeless or in transitional housing who mostly have Medicaid or no insurance. We are staffed with two medical providers, two clinical social workers, and many other incredible staff who work together to give our patients an engaging and productive visit.

For a lot of the patients at Project H.O.P.E., the health center is a home base of sorts. Project H.O.P.E. is a place where people recognize their face, a place to have their mail sent in time of complete homelessness, and a place that knows their story. The staff recognize patients’ individual obstacles and successes without judgment, but with curiosity and determination to create solutions.

What does it mean to meet patients where they are?

A patient I will name “Jane” is a regular at Project H.O.P.E., spending equal time with both the medical provider and social worker. While the entire team works to determines a treatment plan for her COPD, for which she is a high utilizer of the emergency room, the social worker is also forging into the rocky and seemingly bottomless canyon of Social Security and mental health resources. Today Jane informs us that she is homeless after moving out of a boarding house where she was physically attacked, paid $600 for rent, and was surrounded by drug use. Her next Social Security check will not be available for more than two weeks.

As a health coach, I immediately begin brainstorming emergency resources that could help Jane. Since she doesn’t have a phone, we schedule a time and a place to meet at the office of Social Services to try and get emergency housing vouchers. Halfway through our wait time, the church that hands out food is nearing closing time, so Jane must get a lunch since she is without a kitchen or money.  In the time she is gone, of course they call her name. Since she does not have a phone, I am unable to reach her and we are skipped in line.

When Jane’s check arrives in the mail at Project H.O.P.E., we immediately begin driving around the city in hopes of finding her. Without a phone number or an address, we must wait to see her in the streets or when she returns to the health center. Luckily, she walked through our doors the very next day and with great excitement was able to pay rent for a new room.

The longer I remain at Project H.O.P.E., the more barriers patients and I encounter while trying to connect with the medical and social support they need.

In order to schedule an appointment or procedure, a hospital or office might require a phone call to inform the patient of the costs that are not covered by Medicaid, but the patient does not have a phone. For colonoscopies, patients must have someone accompany them and be able to transport them “home” on the date of their procedure, but the patient does not a “home” to be taken to. A specialty medical provider’s office is located out of Camden and would require a 15-minute commute by car. A needed medication is dangerous to carry around on the streets and is often stolen because the patient does not have a room with a lock. A patient’s mental health is constantly in decline because their insurance doesn’t cover their medication. A 45-year-old patient doesn’t have health insurance and is ineligible because of a drug possession charge that occurred when they were 15 years old.

And to think, many of these obstacles could be overcome with very common items: a phone, a room with a lock, a car, a caring family that provides support.

What we’re doing in Camden is beyond value because we are collaborating with our patients and with other organizations to create a solution that works for the long-term and is based on our patients’ individual situations. The ability to laugh and create relationships through these difficult obstacles and successes is what builds trust and eventually leads to an improvement in the quality of health for the patients we work with.

While there is not one obvious solution for all of the problems, there is hope in the fact that our patients do not give up and they do not grow tired of trying different solutions.

“Do not be daunted by the enormity of the world’s grief. Do justly, now. Love mercy, now. Walk humbly, now. You are not obligated to complete the work, but neither are you free to abandon it.”   – The Talmud

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