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Continuum of Care

Unique nurse liaison program puts patients at the center of care.

Throughout her career as a medical social worker and hospital discharge planner in the Bay Area, Joanna Smith, MPH, LCSW, could see care gaps when patients changed from one level of care to another. Discharge planners put together a great plan of care, but when the patient was discharged home or to a rehab center, the plan wasn't always followed, or circumstances dictated it be changed. Patients preparing for a hospital stay weren't clear on the processes and procedures they'd face. Patients in every level of care were confused by the mountains of insurance paperwork they faced.

Joanna Smith, MPH, LCSW

Smith knew the best way to help patients, to be a true patient advocate, was to have one person follow one patient throughout the continuum of care, but that model didn't exist in most healthcare settings.

So she designed her own, and the Berkeley-based Healthcare Liaison Inc., was born.

Patient Advocacy

Smith said the model calls for an experienced healthcare professional trained to handle all age groups, from the beginning of a person's life through the end. Social workers and nurses fit the profile the best because of their experience across the continuum of care, but physicians and PAs also make excellent advocates. She searched for programs to emulate and found some independent patient advocates and a master's program at Sarah Lawrence College, Bronxville, NY, focused on patient advocacy, but nothing standardized that would offer a credential covering all the facets a patient liaison would need to know. Seeing that gap, she created her own credentialing program.

"I developed the first credentialing program in the country for medically trained patient advocates/liaisons," she said. "Healthcare professionals come into the 1-year credentialing program knowing medicine; I teach them other skills on top of that to let them assist patients with insurance issues, healthcare questions and getting through the system. One provider for one patient, from beginning to end. It's what nurses are trained to do - I help them set up a business plan. The only requirement at the end is that providers cannot work for patients in their own healthcare systems, to avoid any potential conflict of interest."

Smith also began the National Association of Healthcare Advocacy Consultants, a private, for-profit organization to look at best practices and national credentialing. She believes a national certification will allow patients to find the best advocate for their particular situation.

"Consumers now have no way of knowing whether the people they're turning to for help really know what they're doing," she said. "Credentialing will let patients know their advocate understands everything that's happening to them and can help them make thoughtful decisions and work through problems.

"Healthcare advocacy is such a big job description," she continued. "Many people are going into the field, which is the good news and the bad news. Consumers can set anyone up to speak on their behalf, so advocates must be true liaisons and work in partnership mode, not become adversarial with the healthcare systems providing care to the patient. My concern is that those going in who are not medically trained go in looking for a fight. For us, it's all about negotiations and finding a way to work within the system to find solutions."

Clinical Focus

Marie Shouldice, BSN, RN, is the first nurse to have completed Smith's credentialing program. A nurse since 1980, she's worked in a variety of fields for several Bay Area medical centers and currently works at Kaiser Permanente's Oakland Medical Center, including her most recent stints in utilization review and discharge planning. She sees her role as a patient advocate as an off-shoot of what she's already doing.

Marie Shouldice, BSN, RN

"I've done much of this work for Kaiser patients while they're here in inpatient, postsurgical care and discharge planning, but my work stopped when they were discharged," Shouldice said. "I started teaching preop classes on my own because patients needed to get the information to know what to expect of the healthcare system and what is expected of them in terms of personal preparation, length of stay, home preparation, in-patient plan of care, discharge planning and necessary durable medical equipment.. I rarely see them after they leave, but know I have prepared them. As a healthcare liaison, the criteria is pretty much the same - it's patient-focused.

"I know the diagnosis, the plan of care, which medications they're on and how they function," she continued. "I'm a human GPS for healthcare - I help patients get through the system."

While she cannot work with Kaiser patients, Shouldice said she works largely with pre- and postsurgical patients from other health systems, brought to her largely by word of mouth. She helps get them ready for hospitalization, advocates for them while they're inpatients, assists with the plan of care, helps with the discharge plan, then follows them at home.


Continuum of Care

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