Team at Angleton Danbury Campus helps patients navigate their way to good health

Jan 20, 2016, 14:40 PM by


Cheryl Vining, a nurse with the Patient Navigation Team at the Angleton Danbury Campus, talks with a health fair participant.

Each day, nurses Cheryl Vining and Darlene Carroll take their mission of improving health to community centers and into patient’s homes throughout Brazoria County.

As part of the Patient Navigation Team at UTMB’s Angleton Danbury Campus, the energetic duo might be attending a health fair, community event or working one-on-one with a patient who needs help in managing a chronic illness.

“No matter where we’re working, I feel like we’re making an impact each day,” said Vining. “We’re focused on improving and promoting health awareness throughout our community.”

ADC’s Patient Navigation Team, funded for the past three years by a grant from the Section 1115 Medicaid Waiver, includes two nurses and a community health worker who visit patients in the hospital who have chronic diseases and anyone who has been re-admitted. The nurses assess patients and help them remove barriers that might be preventing them from improving their health.

Once patients are discharged from the hospital, the team continues working closely with them to ensure that they remain on a path to improved health. Team members provide patients with educational materials, disease-related equipment such as glucometers, scales and blood-pressure machines, and clear communication about their illness and treatment.

“We’ve found that the No. 1 barrier that our patients are facing is a lack of health literacy,” said Carroll, who is the Patient Navigation program manager. “In fact, studies have shown that 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. That’s where we come in, by helping them obtain these skills that are so vital.”

Carroll said that adults who struggle with health literacy are more likely to lack health insurance, suffer from poor health, have a higher rate of hospitalization and less frequently use preventive services. As a result, these patients end up being re-admitted to hospitals or make frequent visits to emergency rooms, both of which lead to higher health care costs.

“Our goal is to help them obtain, process and understand basic health information so that they will be more informed and able to make future health decisions,” Carroll said.

Both Carroll and Vining said the team’s community health worker plays a significant role in helping ensure that patients in the program receive the assistance they need, whether that includes lining up transportation so they can get to and from their physician appointments or helping them complete food stamp applications.

The community health worker’s role is to assist patients with resources, educate according to the care plan developed by the care manager and provide patient support.

“This team approach ensures the patient receives the necessary tools to self-manage their health care and chronic disease,” said Carroll.

Under the terms of the 1115 grant, the program is open to patients who live in Brazoria County, have a health-related barrier to care and have a major chronic illness. 

In 2015, the team not only helped more than 400 patients through its program, it also interacted with more than 2,500 people during various community events held throughout the county. Often, at community health care events team members work from a 26-foot mobile medical unit purchased by the grant. The unit includes a private exam room, digital education station, lab station, plus a laptop documentation area for nurses and physicians.

Recently, the team conducted screenings at Memory Matters Mini Health Fair, an event held at assisted living centers where seniors are tested annually for warning signs of Alzheimer’s disease, including memory loss.

“Memory Matters is an example of a partnership with various organizations reaching out to the community and providing them a service that they may go without or not be able to afford,” Carroll said.

Vining said that while the program’s grant is up for renewal this year, she’s hopeful that it can be expanded so that the Patient Navigation Team can reach even more people in the coming years.

“My ultimate goal for the program would be to bring in another practitioner and a physician and take our mobile unit to the far reaches of Brazoria County,” she said. “I’m a firm believer that we should be reaching out to the people who can’t come to us.”