Transcription:
Caregiver Navigators - Unique Support for Caregivers Right Here in Ventura

Maggie McKay: If you've ever taken on the role of caregiver, you know how emotionally and physically draining it can be. But thankfully, there's an excellent program to offer assistance. Today, we'll talk with Maureen Hodge, Community Memorial Healthcare's High-Risk Program Manager, about the Caregiver Navigator Program at Community Memorial, which provides unique support for caregivers in Ventura.

This is Wise and Well, presented by Community Memorial Healthcare. I'm Maggie McKay. Welcome, Maureen. Thank you so much for being here today. It's a pleasure to have you.

Maureen Hodge: Great. Thanks for having me.

Maggie McKay: And thank you for talking about the unique and very successful Caregiver Navigator Program that you have at Community Memorial Healthcare.

Maureen Hodge: Yeah, it's been quite an exciting couple years launching the program, starting from nothing to what it is today. So, we're really happy to see its progress.

Maggie McKay: And did you start it?

Maureen Hodge: So, the program started back in 2020 and I got in right as we were launching. We hired the first staff, and then I came in as the manager right as she launched. And so, yeah, I'm just part of the launch team, I guess, yeah.

Maggie McKay: That's so exciting. So, you can really tailor it to your community. And I heard your American Hospital Association interview about caregiving, and you described how caregiving can impact anyone of any age. And it's a broad need and it can hit almost anyone. So, can you explain about caregiving and how it's needed for more than just medical needs or issues?

Maureen Hodge: Sure. Well, a caregiver comes into the system, some people don't even know they're a caregiver, but it could be a neighbor, a friend, a mother, father, aunt, uncle. And a caregiver comes into the family system because maybe their mother has Alzheimer's or maybe a son is caring for the mother or father, or a young mom might be caring for a disabled child. So really, a caregiver comes in all shapes and sizes, any background. And there's an emotional toll, there's a psychological, physical cost often to a caregiver. Some people are just like, "Oh, well, no, this is my role. I do this for my mom all the time." That role they take has a mental and physical cost to them, whether they're taking off work for the day to take their loved one to the appointment or they are having to pay for a caregiver for the few hours they go to work every day. So, our caregivers really face so many different issues in their lives that sometimes they're very acutely aware of them and others are like, "This is just what I do." So, caregivers often just have all sorts of physical, cognitive, psychological, developmental issues and needs that are really well rounded. They come to us with all sorts of needs.

Maggie McKay: Maureen, you bring up a good point that it's not just older kids caring for their parents, which is what I always think of when I hear caregiver. You know, your parents are later in life. Like you said, it could be a young mom with a disabled child. That could be so many circumstances. So, what is the role of a caregiver navigator?

Maureen Hodge: Yeah. So, here at Community Memorial, we started this program out of a pilot. Three hospitals in our county started it. And at our hospital, we looked at using our ambulatory, our outpatient program. So, our caregiver navigator could be very well connected to the doctors, and we looked at the caregiver as this primary source of support for the patient. And so if we have a patient that's having all sorts of maybe mental health issues or substance use issues, or complex medical illnesses, and they just have a great need for more care, we decided this could be a referral.

Anyone in our ambulatory could be a referral for a caregiver navigator. And the navigator comes alongside patient's loved one, whoever that might be. Sometimes it's a neighbor, a child, it could be anybody, and really helps troubleshoot with that family identified person to look at all of the social determinants of health, like what's their housing, their neighborhood community? What resources are they using or not using? What's their social context, their economic stability? All of these things really play into the ability for a patient to be stable. And so, the navigator meets with the caregiver one-on-one, kind of understands their story, their history. We are fortunate because we have a licensed clinical marriage and family therapist as our caregiver navigator and she has just done a remarkable job connecting with families and, in their crisis state, help them become more stable.

So, the caregiver navigator just works on anything they might need, getting them resources, getting them better acquainted with their primary care physician if that were the need, just having better conversations, like knowing how to ask questions of their PCP for their patients. So, we're able to do anything with the family based on whatever their needs might be.

Maggie McKay: That is amazing. And you know what, a lot of times we find ourselves as a caregiver and we didn't even know we were. Like, let's say a neighbor has nobody else and you check on them and you find out they're in need of help and you don't know what to do. So, that would be so useful. It's such a unique role and such an important one. You know, social workers have helped with patient navigation, but rarely are the caregivers considered.

Maureen Hodge: Yeah. So across the country, it's really something everyone's paying attention to. Because I think, when you have the patient in the hospital, there's this acute crisis and a social worker, you know, I worked inpatient for many years as a social worker, you are working to try to get them stable, but you have them for those few 20 to 30 minutes or an hour maybe to make sure all their resources are buttoned up and you senD them out the door, which is so needed.

But the caregiver navigator is able to really follow them along the whole journey. And so, I think that has been something we've really seen in this program. We were able to do in this pilot, we worked alongside Channel Island's State University, who's helping evaluate it. And we look at everything from how's the depression, the anxiety of the caregiver, has it gone up or down with the caregiver intervention and the navigator intervention, to everything with what's the relationship, has it been improving with their primary care provider. And, you know, the navigator's unique abilities to be able to make connections, give them resources, help lower stress by giving them-- maybe they just needed food resources or maybe they needed better transportation to get their loved one to their appointments, all of these things make the caregiver feel more connected to the patient and being able to help the patient. So, we've just seen quite a remarkable improvement for the whole patient and that we get to follow them ongoing until we can sense that there's a stability now. They know where to go. They know how to get the help they need.

Maggie McKay: That's so reassuring. I understand that Community Memorial identified the need for this position and program based on your community needs assessment. Can you tell us a little bit about that?

Maureen Hodge: Yeah. So back in 2019, we have a Ventura County Healthcare Assessment that's done, a community health needs assessment that's done. And we really found back from that assessment that the caregiving crisis is upon us in our county. By 2030, 77 million Americans across the US will be aged 65 and over. And boil that down to our county, out of that needs assessment, people identified like, "We are having a crisis with caring for our loved ones, how do we get help?" That really came through the needs assessment. And so, this was that opportunity that Community Memorial was very proactive in saying, "We want to be a part of doing something different and seeing if we can move the needle and help our caregivers now." And it really makes perfectly good sense now that we're seeing it so successful, but it makes a lot of sense that the patients can't do it alone. They really do rely on their loved ones to help them.

Maggie McKay: And Community Memorial is part of a national caregiver navigator program as you mentioned earlier. What planning and capabilities were needed to launch this program?

Maureen Hodge: Well, we had a lot of support with three other hospitals being willing to launch. And we had a great example from another hospital up in Santa Maria, California, who had launched it already and saw amazing results. And then, I got involved with the American Hospital Association, which just helped us keep refining what we were doing. And one of the things that we brought in was looking at all our community partners in our county. We started and launched the caregiver collaborative. So, anyone working in the space with any caregiver come to the table. And it is amazing how many organizations work with caregivers every day.

And so anyway, lots of things have come locally. But now, because we've been measuring this and we're looking at this pilot, you know, we're into year three right now, we're being noticed nationally because it's working. And being able to provide a navigator to come alongside a caregiver so the patient improves, staying out of the hospital, readmissions, all these kinds of things, it's become really well noticed now. So, we're really excited about the national attention the program's getting.

Maggie McKay: That's great. Well deserved, I'm sure. With Community Memorial in their third year of this program, can you tell us what results and maybe some successes are that you've had?

Maureen Hodge: So yeah, in our third year, we have seen amazing successes already. The decrease in readmissions would be one, both for the caregiver and care recipients. So, we decided, you know what, we're going to measure both. Are we able to keep the patient at home and more stable and the caregiver, and both of those have succeeded. We've seen a decrease in readmissions. We've seen an improved relationship between the physician and the patient and caregiver. So, the comments back actually have been so, so sweet. One of them was like, "I never thought that the healthcare industry cared about me like this," like to the caregiver, like how they felt so much more cared for and they could talk to their doctor better for their loved ones, and we see the numbers to support that. So, it's not just the stories, it's the actual pilot that we were evaluating this. The decrease in anxiety and depression of the caregiver, a hundred percent. I shouldn't say a hundred percent went down, almost a hundred percent have gone down. It has been amazing. We've seen that decrease in both of those.

But the other big success is seeing the resiliency of the caregivers has increased. After working with our navigator for about two months, kind of on that third month, depending on what they're coming in with, we see kind of the stability. Like all of a sudden, the resources are there, they feel like they're connecting, they know where to find things. We're checking in every week. And then, you know, we see the resiliency go up. So, that's been really encouraging.

Maggie McKay: Maureen, can you give us a recent example of maybe how you've helped a caregiver in the community, somebody that you remember?

Maureen Hodge: Well, yeah, we have quite a few. We've served over 250, so I think that is remarkable in itself. With 250 caregivers and then multiply that with the family members that that impacts, it has been amazing. But this one story really touches our hearts. We have an 80-year-old father who lost his wife and son within 10 days of each other, just happened kind of really quickly and suddenly for him. They both passed away, but he was left with his 49-year-old daughter who has Down Syndrome. And the daughter was never connected with a medical professional. She had been at home with her family all her life. They were a very closed system. There was no abuse or anything. The home is safe, but it was a very closed system. And so now, the father has to do everything for his daughter, which he didn't have to do. Changing diapers and showering, like that was his wife's job.

So, the caregiver entered into the system and has helped the father on so many levels. We got them connected to our primary care physicians. We got her enrolled in Tri-Counties Regional Center. We got IHSS, In-Home Support Services, to come in a few days a week, so the dad doesn't have to shower and change his daughter anymore. We got her connected, both of them, to the caregivers for the elderly. So, they do the grocery shopping for the dad, and they provide transportation.

And then, one of the big perks is we looked at what services are really close to their house that could help. And there was an adult day program. So now, she's going to get socialization in a program. So if for some reason he passes away, she's already getting socialized and getting out in the community and finding her own independence the best that she can. So really, we see that as just like this is a family that needed immediate help and that has been an amazing success story.

Maggie McKay: You're right. That is beyond heartwarming and what an improvement to their quality of life, both of them, the dad and his daughter, even though that it's so sad circumstances, but still.

Maureen Hodge: For sure. I got to talk to him, Janice talks to him. But one of the things we saw is he relied on these phone calls every week until he's now more stable. So, it was like the caregiver navigator just came around, and you're not alone, got all these services to his house that he'd never had before. So, we were really happy about that. And, you know, you see a lot of families, they just need that support until they get stable. And then, they're like, "Okay, I can do this." And now, the doctor's more involved. The doctor knows what's going on at a better level too. So, I think all of these things really add up to helping the patients get stable.

Maggie McKay: Oh, I'm sure. Maureen, how can patients access your services, or how can they find out more information on the caregiver navigator program?

Maureen Hodge: Yeah. Well, for sure, they can talk to their CMH physician and ask for a referral. We are located with our Community Memorial Health Centers. So, any patient in our Community Memorial Health Centers, if they are there and the provider or the doctor is like, "This family needs help," they can call us at our number, is 805-948-5803. And they can also visit mycmh.org. Any one of our doctors can task us and we can respond right away. If you task high risk, we can be found right away on our EHR. So, we love to hear from caregivers themselves and/or the providers. The providers are great at giving us referrals and we always welcome them.

Maggie McKay: I am so happy to hear about this program and I hope more hospitals take it on because it sounds invaluable to people going through it because, you know what, it's no easy task being a caregiver. So, thank you so much for what you do and for sharing this program with us, so now more people can use your services.

Maureen Hodge: Yeah. Well, I'm so happy to share it. It's been really an exciting time for us and happy to be doing that with CMH. So, thank you.

Maggie McKay: Thank you. Once again, that's Maureen Hodge. Again, to find out more, please visit my mycmh.org. That's mycmh.org or call 805-948-5803. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you.

This is Wise and Well, presented by Community Memorial Healthcare. I'm Maggie McKay. Thanks for listening.