“We’re navigators and case managers,” says Marg Sanderson of the more than 80 client care coordinators who help patients and families navigate an often complex healthcare system.

“Many times when people call us they don’t provide us with a lot of information, so we have to figure out what we need to know to initiate the services that are going to help them,” says Sanderson, the acute care educator with Client Patient Access Services (CPAS).

Marg Sanderson, acute care educator with Client Patient Access Services, has been working with clients in both hospital and the community for 28 years.

Marg Sanderson, acute care educator with Client Patient Access Services, has been working with clients in both hospital and the community for 28 years.

“We’re always aiming to find what is going to work best for the client given their situation and needs,” adds Shelly Panchuk, a client care coordinator who has been working with CPAS for almost 30 years.

There are two areas where client care coordinators work: in the community, including rural areas within Saskatoon Health Region, and in acute care at the hospital.

Client care coordinators in the community

“Community-based client care coordinators provide support to, and coordinate services for, clients to enable them to remain in their own homes with the goal of preventing unnecessary hospital admissions. They also complete long-term care assessments for clients with complex care needs who are no longer able to be cared for at home,” Sanderson says, explaining that CPAS is the single entry point for clients and their families into a variety of community programs and services, many of which are offered through Saskatoon Health Region.

For example, home IV therapy makes it possible for patients to manage their intravenous antibiotics in the comfort of their homes, while direct client funding provides monthly funding and support to assist people with their care needs so they can return home rather than live in long-term care. Home Care, transitional care beds, and community therapies (e.g., physiotherapy, occupational therapy and social work) are also available to clients in a community setting.

Before these programs and services merged under CPAS’s umbrella, clients received separate assessments for each program instead of a single assessment for all services.

“Now we do one assessment, and then navigate the client into the most appropriate services to meet their needs,” explains Sanderson. “In this way, it’s a lot more user-friendly for clients and their families, because they deal with a CPAS coordinator who provides guidance on which services they might need and helps them arrange these services.”

The coordinators need to have a good understanding of available community resources and stay current with their knowledge, because they also provide information to clients about community-based services, such as personal care homes, community housing options and a wide variety of community agencies.

“We have to be creative in problem solving with every client,” says Sanderson. “For example, Home Care may not be able to provide services to a client who is in a high-risk living situation, so we have to be creative in exploring where that client can go to receive the services that he or she needs.”

Advocacy is a large part of a client care coordinator’s job.

“At times, clients need services that are not available to them because of service limits, costs, wait lists or other barriers,” says Panchuk. In those cases, a coordinator advocates to the service provider on behalf of the client and/or encourages the client to accept other referrals for services they may not have initially had in mind.

Client care coordinators in acute care

“We also follow our existing clients through their continuum of care, so when someone is admitted to hospital who is already a CPAS client, an acute care coordinator will immediately connect with this person and follow him or her until discharge,” explains Sanderson.

For example, if a CPAS client is admitted to hospital for planned surgery, his admission will be recorded on a daily hospital admission and discharge list that indicates which patients are also CPAS clients. As a CPAS client, he will have an acute care coordinator meet with him after surgery to determine what services, such as Home Care, he will need when he returns home. The acute care coordinator will also ensure that his care plan is updated and forwarded to the appropriate service providers. Following discharge, his community coordinator will resume follow up with him at home.

Acute care CPAS coordinators also see new clients in hospital who have not previously been connected with CPAS. Coordinators regularly attend patient rounds with physicians, nursing staff, therapists, social workers and other team members to identify which patients may require CPAS services.

“We’re very much a part of the patient’s interdisciplinary team in the hospital,” says Sanderson. “We receive a lot of referrals from other team members. We might bump into one of the physiotherapists, who says, ‘By the way, I was walking so and so and they’ll need help when they go home.’ That’s a referral to us. It’s a very informal process. We also get referrals directly from clients and their families.”

The objective of the acute care CPAS coordinators is to make sure that clients receive timely services to facilitate safe discharges to their homes within Saskatoon Health Region or other health regions, to acute care hospitals in their home health regions, or if necessary, to an alternate setting, such as a transitional care bed or a special care home.

“CPAS is an integral part of the patient flow system,” Sanderson explains. “If we don’t move people through the system quickly and safely, we’re in a position where we can’t meet the demand for beds. So, CPAS is a very important part of the team that helps determine who can be discharged and where they can be discharged to.”

“We’re not involved in bringing patients into the hospital and placing them in beds like ACAS,” she continues, “but we do start following patients as soon as they’re admitted to hospital. We look for options that will safely meet their care needs when they no longer need the level of service that a hospital provides, freeing up their hospital bed for someone who does need it.”

Sanderson says one of the most satisfying aspects of her job is being able to help a client return to the living situation of their choice.

“What gives me satisfaction is seeing results – it’s seeing clients discharged home with support services, providing ongoing support to them in their home or assisting them to access long-term care if they’re unable to return home. We’re here to offer support to clients and their families in making important and often difficult life changes,” she says.

At the end of the day, community and hospital client care coordinators are very similar, she adds.

“Each assesses clients and determines the appropriate services for them,” she explains, adding that she has worked in both hospital and the community over what has been a very fulfilling 28-year career.

This article is part of a three-part series.

Acute Care Access Services: Safely placing patients in the right beds (Part 1 of 3)

Acute Care Access Line: Linking physicians to provide better care for patients (Part 3 of 3)