I was part of the Health Links program when it was a pilot project that worked with the 150 of the most vulnerable members of our community. These are the clients who had worked with a number of other agencies but still fell through the cracks.
Our goal was to keep people out of hospital, and as often as possible, keep them home and healthy. It was an amazing project to be part of.
We went where they needed us. We did prenatal exams in the back of cars. We’d see patients in back alleys. Sometimes an abusive situation meant we couldn’t meet people in their homes, so we’d meet in a coffee shop. There were even times when the best could do was to leave notes for the client to try to set up a time to see them.
What I do now is not at the same intensity or the same complexity, but you can be part of preventing those complexities.
Sometimes it’s easy to focus on the negative. It can be easy to judge someone because they have an addiction or behave a certain way. The approach we took on health links was to start with the positive, which really helped to change perceptions. It could be something as simple as “You won’t believe the joke they told today” or commenting about how motivated they were or talk about their small successes. Focusing on the positive forces you to think in a different way.
If you start with the negative, then right away you don’t see the client as a mother, father, brother, sister or child, you see them as a problem. I think we need to look at the person and see their potential. Let’s figure out what makes them tick. Let’s figure out why they’re having the problems they’re having. Let’s see if they are interested in letting us help them. Not everyone is interested in getting help.
It’s easy when you do this all day every day, to go through a checklist with each client. We have to go through a process to offer them services, but some people may have never had contact with us before. It can just be too much. My philosophy is that you end with services; you never start with them.
If you stop and listen to a patient’s story, you can become an advocate for any patient.
I remember one patient really well. It was the first time I saw the system work in a totally different way. Time and again, we would find him in crisis and would have to bring him to the hospital. At the time, we hadn’t discussed whether the health links coordinator should go into hospital, but it didn’t make sense for us not to be involved in his discharge planning.
His apartment had burned down, and he was released to a shelter with no clothes. When he was re-admitted that time, we got really involved, and every day we would advocate for him to stay longer. He ended up staying for 15 days – and went beyond just stabilizing. He got so much better. He got cleaned up. He was super motivated.
As a result, he wasn’t readmitted for years. That intensive care coordination for a short amount of time led to years of non-admissions. He had stable housing, friends, and was able to connect on a human level again instead of covering his pain with substance abuse. Eventually, he will go back to hospital, and he will become palliative. But until he does, he has a chance to enjoy his life.