December 15, 2015

Health Navigation: Dallas County’s Beacon of Health

How do we connect our community’s public health resources to the people who need them most? In Iowa, the Dallas County Health Department established Health Navigation to help community members through the complex and often daunting process of receiving health services. The need for the initiative became apparent in the findings of the Dallas County Community Health Needs Assessment (CHNA) released in 2010. The CHNA revealed the community’s confusion regarding healthcare resources. Without a central point of communication or organization, many individuals and families were unable to access services they needed.

Enter Health Navigation
Health Navigation’s small team of three staff members displays a wide range of backgrounds and experiences, enabling the initiative to link families to valuable resources throughout the community.

A social worker by training, Ann Cochran serves as a Health Navigation Coordinator, bringing to her work a deeply held commitment to enhancing the well-being of members of Dallas County’s communities.

Vivian DeGonzalez started working in Dallas County in 1999 as a liaison, connecting families to resources in the county. When a Health Navigator position opened, Vivian knew her background as a translator for Spanish-speaking members of the community would allow Health Navigation to help even more people.

As Dallas County’s Community Health Coordinator, Jennifer Walters uses her background in public health and her experience organizing and implementing initiatives to evaluate Health Navigation.

The Small Victories Matter
Despite the small team, Health Navigation amasses victories in their work every week.

When the eight-year-old daughter of recent Iranian immigrants started complaining of unusual pressure in her mouth, her parents knew she needed a dentist. Without the resources to find a dental office or afford transportation to an appointment, the family did not know how they would take care of their little girl. Earlier in the month, Ann provided their neighbors, also Iranian immigrants, who were expecting the birth of their first child, with information and materials to connect them to maternal and pregnancy resources. When this family heard of their neighbors’ dental troubles, they suggested calling Health Navigation.

Immediately, Ann made a lot of phone calls—to the University of Iowa, to the bus company, to the dental office to provide it with the daughter’s records. Medicaid could not pay for transportation into Iowa City, so the family, who fortunately owned a car, made the four-hour, 265-mile journey themselves. Despite that minor hiccup, Ann managed to get the family reimbursed for their mileage. Not only did she schedule their appointment, she also arranged for an interpreter to greet them when they arrived and help them through the maze of the University of Iowa hospital.

As it turned out, the daughter’s small mouth was too crowded with baby teeth, which were blocking the incoming adult ones. Because of Health Navigation, she received the operation that removed the problematic teeth.

Sometimes factors of day-to-day living create the greatest obstacle to health. A client of Vivian’s, suffering from the effects of multiple strokes and chronic obstructive pulmonary disease (COPD), found herself physically disabled and overburdened by mountains of paperwork. She reached out to Vivian, her Health Navigator, who steered her through the bureaucracy of the healthcare system.

When Vivian arrived in the client’s home, she found herself in a sitting room, crowded with boxes of dusty newspapers and other items hoarded over many years. Sunlight flitting through the closed window illuminated cat hair listlessly floating in the air.

As they worked together, Vivian learned that her client found the amount of paperwork paralyzing. She saw she needed to segment the paperwork into small portions and help her client to complete each form. Rather than connecting her client to additional resources, Vivian became the resource, giving her client the confidence and peace of mind to take back control of her life from her illness and the red tape entangling her.

Whether clients have mental or physical health issues or are in crisis, frozen with anxiety and panic, Health Navigation’s services, which might appear minor from the outside, mean the world to them. Health Navigators serve as boots-on-the-ground for public health in Dallas County, providing services of all sizes to the most vulnerable in the community.

The Most Difficult Part of the Job
Even with Health Navigation working tirelessly to connect community members to the resources that will improve their lives, such as heat for their homes, physical therapists, and psychological counselors, people very often resist change. Mental health issues provide a particular challenge. Although people find themselves in painful and uncomfortable places from which they desperately want to move beyond, change can be difficult.

We are creatures of habit, after all, and lifelong patterns—even harmful ones like unhealthy diets, unsafe living situations, and drug and alcohol abuse—become deeply embedded in our understanding of ourselves and the world around us.

In a place like Dallas County, which includes diverse cultural demographics and both urban and rural communities, not every client becomes a success story. One uncommonly warm Iowa November day, a young man and his mother met with Ann in the office. The mother, fraught with worry, feared for her son’s future. He was nearly 20, though his demeanor made him seem as if he were barely out of adolescence. Despite his mother’s distress, he maintained his attitude of eye-rolling cynicism. He was recently released from jail after fighting with his step-father and needed a job and a place to live. He could not go home to live with his mother because of a no-contact order between his step-father and him. He seemed unconcerned, however, believing that within a week he could find a job and an apartment and return to a comfortable standard of living. Ann explained to him that within a matter of days they would experience the sharp and slushy force of winter in Iowa, and he needed to get off the streets as soon as possible.

The terms of his probation required him to stay in Dallas County. But without any men’s shelters or temporary homes for men in the county, he had nowhere to turn—except Health Navigation.

Ann referred him to one of her connections in Des Moines, a non-profit organization called Freedom for Youth, which could connect him to a men’s shelter. With her credibility, she knew she could arrange for his probation officer to agree to allow him to live in the city (which is located outside of Dallas County). The Health Navigation team arranged a bed and everything else he might need. A Freedom for Youth employee even agreed to give him a ride to the shelter.

Despite all the unified hard work, this young man declined the offer. Even with their vast network of connections and their determination to promote positive health outcomes in their community, the Health Navigation team must still respect the free will of their clients—and times when their clients refuse help can be the most challenging part of the job.

It’s not only clients who resist change. Clinic doctors can be reluctant. When doctors fear referring patients to Health Navigation will create more work, the Health Navigators must toil harder to demonstrate that, in fact, their work will allow providers to focus their time and expertise on addressing the patients’ medical needs. The Navigators can help remove the social barriers keeping patients from taking the actions they need to be healthy.

When a frustrated doctor wonders why her diabetes patient is not compliant with his regimen, Health Navigation can work closely with that patient and bring to light the dangerous and unhealthy conditions operating behind the scenes. Perhaps the patient lacks enough income to buy the type of food he needs to eat. Perhaps he cannot afford a membership at the wellness center for exercise. The patient wants to be healthy, but stumbling blocks get in the way. By working with clinics, Health Navigators can let doctors be doctors—and they take care of the rest.

But the Good Work Never Ends
In Iowa, winter chills reach an average of 21.7 degrees Fahrenheit. With winter rolling in, one family living in a rural area needed a way to heat their home. The mom worked during the day, while the dad stayed home with their three children; both adults were intellectually low-functioning. At low winter temperatures, the lack of heat spelled bad news for everyone, but it promised to be especially dangerous for their vulnerable children. They contacted Health Navigation and the team introduced them to the Low-Income Home Energy Assistance Program, offered through the local Community Action Agency.

Vivian visited their home to investigate the family’s particular situation. She saw it was much more complicated than just their needing to pay the gas bill. Health Navigation had a lot of concerns about the parenting and the relationship between the two adults in the home. The way they interacted and worked together did not appear to provide financial sustainability for their household and, in this stressful situation, put the children at risk for abuse.

Through the home visit, Vivian captured all of the dynamics of the household. Taking a look at their living situation, the team managed to diagnose the harmful environmental circumstances. If they only got the gas turned on, would the family have been able to continue paying for it? Health Navigation introduced the family to an evidence-based, long-term family support program that provides families under stress with financial assistance, free transportation to attend appointments, and a free clothing closet for children. Because of Health Navigation’s approach of visiting homes and examining circumstances, it was able to connect the family with resources and educate them on services that provide financial, social, and parenting assistance.

Light through the Jungle
As Health Navigation expands its vast network of health and wellness resources, the initiative serves as a paragon for healthcare work throughout the country. Barriers to the well-being of members of our communities are not always medical. Sometimes the resources are there, hidden in a dense jungle of paperwork, rules, economic obstacles, and systemic conditions. While doctors support health in their patients through clinical visits and prescriptions, Health Navigation goes deeper. Health Navigators will go into the home. They can see the environments in which patients live, and they can identify the often unseen root causes of illness and injury. By infusing the public health system in Dallas County with a profoundly human element, Health Navigators are guides, lantern beams poised to shine through the labyrinth and ensure no one gets left behind.

This story is based on interviews with Jennifer Walters, Ann Cochran, and Vivian DeGonzalez. The Foundation for the Public’s Health thanks them for sharing their stories about Health Navigation with us.

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