Care Navigation: Connecting Clients to Required Supports - Yorktown Family Services
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Care Navigation: Connecting Clients to Required Supports

Yorktown’s Care Navigation worker helps children, youth, young adults and their families (birth to the age of 29 years) who require complex care mental health and social service support get the right support, at the right time, within a framework of an integrated care team at Yorktown, and linking them to outside external networks of support. Care Navigation increases access to services and facilitates wrap around support. The outcomes are strengthened mental health functioning, increased social participation, and support of youth in acquiring the social determinants of health so they can live healthy lives.

Natalie Walsh is an Addiction Counsellor at Humber River Hospital whose focus is Early Intervention and Psychosis under Outpatient Addiction and Mental Health, a division that is managed by Darlene Ginsberg.

Natalie became acquainted with Yorktown’s Care Navigator Role through a presentation from Chantal Senechal, Yorktown’s Care Navigator. Natalie felt that this would be an important resource to connect numerous patients to as they would benefit from the bridging between hospital and community services that the Care Navigator provides. It was important that connecting her clients to Yorktown’s Care Navigator, could be done through a “warm transfer”, that is, Chantal would join Natalie and her client at a regularly scheduled meeting at Humber River Hospital to meet in person for the initial introduction.

According to Natalie, “A warm transfer is really important for many of the patients that I work with. There is a varying degree of wellness among the patients that I see and the warm transfer is especially important for those that suffer from paranoia or have a high level of anxiety around phone calls. This is actually a common factor that many require support around. Once the patient has met with Chantal, they are more comfortable; this greatly enhances the likelihood that they will attend subsequent appointments with Chantal, preventing them from being lost to service.”

The Care Navigator fills a gap that exists in bridging patients from hospital to community services. Once the warm transfer has been made, the Care Navigator meets with the client and works with them to connect them to services in the community that they require. Chantal also uses a warm transfer to connect her clients to other service providers. “The referral can be made, but for many clients, making the connection through a warm transfer will increase the likelihood that they will make it to their appointments. I continue to keep in touch with the client until I am sure they have settled in with the new service, helping to ensure that they follow through with appointments, and get the support in the community that they require,” says Chantal.

Natalie connects patients who are ready for discharge from the outpatient program to Chantal. Rebecca* is one such patient. At age 19, Rebecca experienced a psychotic break and was hospitalized at Humber River Hospital under the care of a psychiatrist. Once stabilized on medication, Rebecca was transferred to Outpatient Addiction and Mental Health, and began seeing Natalie. Natalie has connected Rebecca to Chantal to support her in accessing the services that she needs, including Cognitive Behavior Therapy. “CBT was an intervention recommended by Rebecca’s psychiatrist. Utilizing Motivational Interviewing, I worked with Rebecca on skill building and education around psychosis and maintaining wellness and she now feels she is ready for CBT intervention,” says Natalie. “Getting the services that are required, when they are needed is critical. In Rebecca’s case, for example, now that she is prepared for CBT, Chantal will connect her to a therapist at Yorktown with expertise in CBT . Chantal will also connect her to other services, supporting her successful integration into the community.”

Since the launch of the Care Navigator Role in February 2019, referrals have been coming in from hospitals, Unison Health & Community Services, Child Welfare and the Toronto District School Board.

According to Paula Villafana, Program Director, Mental Health & Addictions and Family Practice Humber River Hospital, “Our collaboration with Yorktown has resulted in the Care Navigation role being made available to support Humber River Hospital patients suffering from a mental illness. Clinical engagement with the Care Navigator has enabled patients to experience seamless, integrated care and timely support”.

The Navigator builds therapeutic relationships through active engagement, problem-solves and helps locate resources post discharge, serving as a link between hospital, community and social services. Using a caring, respectful approach, the Care Navigator advocates for the health needs of patients and families while focusing on recovery. From our experience, the position plays a crucial role in helping the patient get the right support, at the right time, to help manage a wide range of health needs.”

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Youth felt 100% of the time, when a Care Navigator was involved, warm hand offs between service providers was helpful in continuity of care.

Despite over 70% of referrals coming from hospitals and primary health to our Care Navigation service, with 28 participants, only 12% of clients required visits to the emergency department while in service.

Quotes from Yorktown Care Navigation Clients:

You’re there when I need you, and you’ve always got answers to my questions.
– Male, age 18; referred by his mother for individual therapy, support to find a job, substance misuse prevention group program.

You’re easy to talk to and you’re able to break things down for me so that I understand.
– Female, age 20; referred from Humber River Hospital for therapy, substance misuse prevention program, social/life skills group, youth mentorship and case management.

#GivingTuesday is only a few weeks away.
Your donation of $75 allows Care Navigators like Chantal the opportunity to meet and provide a 1.5 hour counselling session for a youth in need. Please help youth living in under-resourced communities be supported with warm transfers and successful integration back in to their community — just like Rebecca!

A “Warm Transfer” occurs when a worker in one program connects the client to another program by personally introducing them to a new worker. The initial worker remains involved to ensure engagement with the new worker, before discharging the client from their care.
Cognitive Behavioral Therapy (CBT) is a structured, time-limited, problem-focused and goal oriented form of psychotherapy. CBT helps people learn to identify, question and change how their thoughts, attitudes and beliefs relate to the emotional and behaviour reactions that cause them difficulty.
Motivational Interviewing (MI) is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.
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