Managing chronic kidney disease (CKD) and end-stage renal disease (ESRD) can be a challenge for many patients. CKD patients often have multiple comorbidities, which may require them to manage appointments with a variety of specialists and a long list of medications, making their health management journey incredibly complex. Furthermore, ESRD patients on dialysis must juggle their dialysis treatment schedule, doctor appointments, and a strict medication and diet regimen, on top of trying to maintain a healthy lifestyle. For those struggling with Social Determinant of Health (SDoH) barriers to care, managing their disease can feel nearly impossible.
The World Health Organization1 defines SDoH as “the non-medial factors that influence health outcomes.” Some examples include unemployment, limited education, food insecurity, unstable housing, and certain living or working conditions. SDoH factors have a profound impact on an individual’s health and health outcomes.
At Healthmap Solutions, we understand the immense value in identifying and addressing these SDoH barriers to care in order to improve CKD and ESRD outcomes for patients in our program. For this reason, all patients taking part in the Care Navigation component of our Kidney Health Management program are screened for social barriers to care. Our multidisciplinary Care Navigation team includes Care Navigators (registered nurses who are responsible for providing care coordination and ongoing support to patients), along with registered dieticians, pharmacists, and social workers. When barriers to care are identified, our team helps to connect patients with resources to help eliminate these barriers to care. Oftentimes, these resources are located in the patient’s community but are unknown to the patient. Examples have included transportation services, meal programs, language assistance, and financial support.
One of Healthmap’s Care Navigators, Deb Hogan, BSN, RN, CCM, has a unique passion for helping patients address SDoH concerns, and she has made significant impacts on patients’ lives through her empathetic support. “I have been a nurse for 30 years, and I have spent a significant amount of time with the underprivileged, many of whom have had complex illnesses,” said Deb. “I’m also a former Director of Nursing for a home health agency, so I have helped patients work through a lot of social determinants of health.”
During her time as a Care Navigator, Deb has helped CKD and ESRD patients overcome a variety of challenges, including housing insecurity, food insecurity, lack of transportation, and unemployment. She explained that Healthmap’s Care Navigators can help patients with almost anything. “The resources we can get for them can make a huge difference,” said Deb. She recalled helping patients submit housing applications, find resources for mobility devices, help search for doctors, and even apply for a charity car. For patients struggling to advocate for themselves, she’ll walk them through the whole process, and even help them make calls if needed. Deb stated, “I tell my patients that I will dig and dig until I find them a resource. Then we’ll make that phone call together. Or I’ll tell them exactly what to say so that they can advocate for themselves effectively. I just hold their hand throughout the process and help advocate for them until they are able to do it for themselves.”
Throughout her career, Deb has always worked hard to find community resources for her patients, but she remarked that the resources available through Healthmap’s Care Navigation team are truly unmatched: “This is the first time I have access to in-house behavioral health professionals. I have a great relationship with the behavioral health staff on our Care Navigation team, so I can always call on them if I feel that a patient needs a referral.”
The expertise of our multidisciplinary team of social workers, behavioral health professionals, registered dieticians, and pharmacy specialists, combined with the support of registered nurses like Deb, allows Healthmap’s program to support personalized, whole-patient care. Thanks to Deb and the rest of the team, we are able to ensure that all patients in our Kidney Health Management program have the tools they need to achieve the best possible health outcomes.
Our Care Navigators are passionate about improving the lives of these patients, and we’re incredibly proud of the work they do. Regardless of a patient’s life situation, our Care Navigators will always be there to help them succeed in their healthcare journey. “It’s all about being a friend and telling them that you’re not going to go away,” Deb added. “This has been my absolute favorite job that I have ever had, because I get to take the time to really listen to these patients and support them.”
We Are Proud to work with Care Navigators like Deb who are making a difference in patients’ lives. We Are Healthmap!
ABOUT DEB HOGAN, BSN, RN, CCM
Deb Hogan is a nurse and case manager with 30 years of healthcare experience in several areas of focus. She previously served as Director of Nursing for a home health agency, and has also worked in hospital, psychiatric care, case management, and insurance positions. As a Care Navigator at Healthmap Solutions, she utilizes her nursing and case management skills to support patients in every aspect of their kidney health journey.