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Becoming an ASF Patient Navigation Fellow

What is the Patient Navigation Program?

The ASF Patient Navigation Program is a new program within ASF where applicants have the opportunity to act as patient navigators within their community project.  While following a similar structure of the Fellowship, being an ASF Patient Navigation Fellow will require applicants to work on specific Legacy projects (see below).

 

Modeled in part on the highly successful Dallas Schweitzer Chapter’s Patient Navigation Program, ASFHG staff will partner with the Patient Care Intervention Center (PCIC) to create a curriculum to train allied health graduate students using PCIC’s Community Resources eXchange (CRX), the most comprehensive referral database in Houston. 

 

ASF Patient Navigation Fellows will also be full ASF Fellows and receive the training and mentorship that all Fellows receive. In addition to this, there will be a curriculum based on what is used by the Dallas Schweitzer chapter’s Patient Navigation Program. This curriculum has provided such a novel and successful way to teach patient navigation to medical students that the results have already been accepted for publication in the scientific literature.

 

This two 2.5-hour class curriculum would be offered to all Fellows but mandated for those projects that involve ASF Patient Navigation Fellows. PCIC would give our ASF Patient Navigation Fellows access to and training on the CRX and the Unified Care Continuum Platform - Community Edition, allowing communication between the ASF Patient Navigation Fellows and the agencies to whom they refer clients. This would enable Fellows to make referrals with real-time feedback and give clients access to the most up-to-date and complete listing of community resources. All ASF Patient Navigation Fellows would be provided tablets for the year to access the CRX in the field.

 

This program will be a ground-breaking enhancement of what we can offer our Fellows and make them better change agents for health equity by digging deeper to understand the underlying systemic reasons surrounding the health outcomes of marginalized individuals. 

Projects involved in this pilot (you must be applying to take on one of these projects to qualify for the ASF Patient Navigation Program):

  • Moms to Moms: This addresses maternal health inequities and literacy through education sessions at Lyndon B Johnson and Ben Taub Hospitals, aiming to improve postpartum maternal and fetal health along with social wellbeing. If interested in taking on this project as an ASF Patient Navigation Fellow, please contact erika.s.fanous@uth.tmc.educara.he@bcm.edu, or Lillibeth.Snellman@bcm.edu.

  • PCIC Integration at HOMES Clinic: Fellows are addressing homelessness in Houston by implementing a social services platform that enables student volunteers at HOMES Clinic (medical and pharmacy students) to be more connected to social service providers in Houston and help coordinate delivery of social services to the unhoused population. If interested in taking on this project as an ASF Patient Navigation Fellow, please contact colton.andrews@bcm.edu or panayiotis.d.kontoyiannis@uth.tmc.edu.

  • Nalox-OWN: Fellows are taking a stand against the opioid epidemic by establishing a naloxone training and resource navigation program for Houston’s unhoused population at the HOMES clinic. If interested in taking on this project as an ASF Patient Navigation Fellow, please contact cplee@utmb.edu or malnguye@utmb.edu.

  • BrIDging Resources: Fellows are addressing barriers to access of social services in Galveston, Texas by assisting with ID application and resource navigation for the unhoused and underserved community. If interested in taking on this project as an ASF Patient Navigation Fellow, please contact anlahitt@utmb.edu or jango@utmb.edu.

  • Project SEED: Fellows are addressing the difficulties the disability community faces in accessing resources vital to their daily functioning and well-being. By engaging in conversations with adults with neurological injuries as well as the families of children with spina bifida, Project S.E.E.D. aims to increase awareness and utilization of resources available to the disability community. If interested in taking on this project as an ASF Patient Navigation Fellow, please contact Madilyn.L.Feik@uth.tmc.edu or sanjay.v.neerukonda@uth.tmc.edu.

  • New Hope Housing Patient Navigation Project (NEW): One of the projects we are very excited about starting is a Patient Navigation project at the Reed location. This project would be a Patient Navigation Program project, in which the Fellow would create a connection with 2-3 families throughout the year and refer and connect them to appropriate resources that they need at the time, with the help of experienced social workers and training given by ASF. If interested in this project, please contact Sandra Martinez (sandra.m@newhopehousing.com) and Cesar Ramirez (Cesar.R@newhopehousing.com) and CC Carol Jacob (carol.jacob@asfhg.org) with the subject "ASF Patient Navigation Fellowship Interest".

Please visit our Current Projects page to learn more about these projects and connect with the Fellows currently doing them.

Requirements for ASF Patient Navigation Fellows in addition to standard Fellowship requirements:

All of the following tasks will be counted as service hours that will be applied to your service hours requirement for the Fellowship.

  • Attend 2-3 additional in person didactic sessions in Houston (around 5 hours total)

  • Use the PCIC database and focus on resource navigation in your project

  • Complete additional quality improvement surveys

  • Attend periodic group Zoom check-ins (around 30 minutes per month)

  • Answer an additional question on the monthly report about your patient navigation experience

If you have any questions or are interested in becoming an ASF Patient Navigation Fellow, please reach out to Program Director, Carol Jacob, at carol.jacob@asfhg.org.

2024-25 Patient Navigation Projects

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Merrick Garner and Carlie Stratemann

UTHealth McGovern Medical School & UTHealth School of Public Health

Project Name: TBD

Community Site: HOMES Clinic

Site Mentor: Dr. Dana Clark; Academic Mentor: Dr. Benjamin King

Fellows plan to regularly meet with people experiencing homelessness (PEH) at the HOMES Clinic and create personalized care plans centered on clients’ values, needs, and goals. From these interactions, information can be inputted to UCCP to determine the most appropriate services available to them. Then, they will facilitate the coordinated delivery of these services to clients by regularly engaging with them to help them access services, plan appointments, and assess whether their needs have changed.

Shivanki Juneja, Isha Parikh, and Richa John

Baylor College of Medicine & UTHealth McGovern Medical School

Moms to Moms

Community Site: Ben Taub Hospital / Lyndon B. Johnson Hospital

Site Mentor: Dr. Irene Stafford and Dr. Efua B. Leke; Academic Mentor: Dr. Sarah Kay Conrad

This project provides education sessions to low-income and marginalized populations to improve postpartum maternal and fetal health and social well-being. Topics for sessions include postpartum depression, breastfeeding, contraception, nutrition, exercise, as well as financial and community resources. The 2024-2025 group hopes to expand the project by recruiting social work and MPH students as volunteers to allow for improved dissemination of resources, increase inter-school collaboration, and expand into the prenatal space like the LBJ outpatient women's clinic.

Madeleine Cluck and Lindsey DeSplinter

Baylor College of Medicine, UTHealth McGovern Medical School, & UTHealth School of Public Health

Project Name: TBD

Community Site: New Hope Housing

Site Mentor: TBD; Academic Mentor: Dr. Rebecca Beyda

Madeleine and Lindsey plan to work with 2 to 3 families facing difficulties navigating the healthcare system and assist with tasks such as finding providers, scheduling appointments, health insurance usage, medication ascertainment, and coordinating transportation. Our primary goal is to alleviate barriers to accessing health services by leveraging existing resources at NHH, like the Reed clinic, and introducing new resources as needed. We will utilize the PCIC database to improve care coordination for residents.

Ashlynn McCall and Jessica Medrano

Tilman J. Fertitta Family College of Medicine

Project Name: TBD

Community Site: New Hope Housing

Site Mentor: TBD; Academic Mentor: Dr. Rebecca Beyda

Similar to the project above, Ashlynn and Jessica plan to work with 2 to 3 families facing difficulties navigating the healthcare system and assist with tasks such as finding providers, scheduling appointments, health insurance usage, medication ascertainment, and coordinating transportation. Our primary goal is to alleviate barriers to accessing health services by leveraging existing resources at NHH, like the Reed clinic, and introducing new resources as needed. We will utilize the PCIC database to improve care coordination for residents.

Neha Dronamraju

UTMB John Sealy School of Medicine

BrIDging Resources

Community Site: CHRISTUS Our Daily Bread

Site Mentor: Angela Joseph; Academic Mentor: Dr. Sarah Siddiqui

The project goals include assisting individuals with acquiring PID documents and connecting them to local community resources. To assist with PID documents, 15-20-minute client appointments will be conducted weekly on a first-come, first-serve basis. During those sessions, Neha will identify the identification papers they seek, what current documents they own, and which ones they need to acquire, and plan a follow-up if needed. We would also review a questionnaire assessing immediate needs, medical assistance, food insecurity, transportation needs, and housing instability and refer them to applicable local Galveston resources.

Emily Minner, Aamuktha Porika, and Sydney Zhou

Texas A&M University School of Engineering Medicine

Project S.E.E.D. (Support, Empower, and Engage with the
Disability Community)

Community Site: UT Spina Bifida Clinic and RSVP (Rehabilitation Services Volunteer Project) Clinic

Site Mentor: Dr. Sunil Kothari, Dr. Jason Au; Academic Mentor: Dr. Ericka P. Greene

This project addresses the gap between resource awareness and utilization in the disability community, specifically among adult patients with brain injuries, spinal cord injuries, and amputations, as well as pediatric patients with spina bifida. Volunteers will engage in 15-30 minute conversations with patients to understand the social and economic resources they are lacking and then connect them.

Alexis Rivas and Gabrielle Becerra

UTHealth McGovern Medical School & Texas A&M University School of Medicine

Project Name: TBD

Community Site: Casa Maria Health Clinic

Site Mentor: Monserrat Viveros; Academic Mentor: Dr. Mary Kollmer Horton

Currently, Casa Maria refers patients to ECHOS, a health and social service for new immigrants, for assistance in applying for the Gold Card. By implementing our project, we can bring that assistance in-house to a familiar place where patients already receive care. We will utilize and build on previous patient relationships and simplify the process instead of asking them to commute to a different resource center. For many patients at Casa Maria, access to a computer/internet is limited, and knowing how to look for resources poses an additional barrier. As a result, our program will provide patients with a concrete place to go to receive information on financial assistance programs like SNAP and WIC in their native language without the need for computer/internet access.

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