In a recent case at Riverside Community Hospital emergency department, we witnessed the power of collaborative care and thorough assessment in addressing complex patient needs. A female patient initially presented with an "other" primary concern, but thanks to the diligence of the ED care team, underlying substance use issues were identified, prompting a Substance Use Navigator (SUN) consult.
The patient's situation was multifaceted, involving recent methamphetamine use, homelessness, the recent loss of her mother, subsequent job loss, and lack of transportation. These compounding factors highlighted the need for a comprehensive care approach with our patient care navigator, Rachel Lomeli, at the helm.
Our SUN team, in collaboration with ED staff, worked tirelessly to navigate the complexities of the healthcare system on behalf of the patient. Despite numerous calls and transfers, their persistence paid off. They successfully secured a same-day detox appointment at a facility in Orange County, aligning with the patient's MediCal coverage area.
To ensure the patient could access this critical care, a Lyft was arranged for immediate transportation to a detox facility. This coordination was crucial in overcoming the patient's lack of personal transportation, which could have been a significant barrier to care.
The care plan extends beyond immediate detox, encompassing a holistic approach to the patient's recovery. Next steps for the navigator’s work in navigating this patient throughout the care continuum include:
1. Securing placement and transitioning the patient to residential treatment upon detox completion
2. Placement planning for the patient’s transitional housing needs
3. Seeking grief therapy resources and arranging appointment coordination to address the recent loss of her mother
4. Providing employment assistance resources to support long-term stability
Special recognition goes to the staff in the emergency department at Riverside Community Hospital for their compassionate support. They provided the patient with water and a sandwich and secured a private room for consultations with the navigator.
This case exemplifies the importance of thorough assessments and deep listening to the patient, asking thoughtful motivational interviewing questions. It also highlights the crucial need for interdepartmental collaboration and persistent care coordination in addressing complex patient needs. By addressing both immediate medical concerns and underlying social determinants of health, we can provide more comprehensive, effective care that sets patients on a path toward long-term recovery and stability.
