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Patient Care Navigation

By May 1, 2017November 24th, 2020No Comments

Going Above & Beyond: Our Patient Care Navigation Program

Supporting patients “outside the exam room” to improve their well-being

Imagine finding your way around the complex US health care environment if you don’t speak English, come from a different culture, or can’t read or write. Or, imagine that you are homeless, can’t afford to buy food, don’t have transportation, are worried about your immigration status, or have experienced bias from health care providers. Understandably, getting health care may not be your top priority; at a minimum, the prospect can be daunting.

At Marin Community Clinics, we know that many of our patients need help navigating the system. We also know that the same social and economic issues that create barriers to accessing care can have a direct impact on their health. (In the industry, we call these “social determinants of health.”) We see it every day – stress-related illnesses such as hypertension, depression and anxiety, and delaying care until it becomes an emergency.

That’s why, early last year, we developed the Patient Care Navigator Program –an innovative approach within the community clinic setting.

Guiding & Advocating for Patients

Patient navigator programs were first developed in hospitals to coordinate medical care for chronic illnesses, but our program goes a step further. We not only arrange for care, but also provide hands-on guidance to help patients access community resources so that their broader life challenges can be addressed. Why? Because we know that if their basic needs aren’t met, they are less likely to be healthy.

Today, Patient Care Navigator Hannah Bichkoff (who is bilingual) works with six to eleven patients/day who are referred by medical providers, community partners, and various departments within the Clinics. She meets with each patient to assess the needs and then begins to “navigate.” This can include accompanying patients to interviews with Social Security, housing programs, and immigration authorities; enrolling them in health insurance; and, reaching out to local charities to donate items such as rental assistance and furniture. It’s not easy work – it requires perseverance, strong advocacy, and a lot of paperwork. And, it can be intense and time-consuming, given the often complex situations and emotional component.

The program works!

“We meet the patient where they are – not judging them, but being understanding and focusing on what is important to them, “ explains Hannah. “ If a homeless family doesn’t have a car and the mom needs to work, how can she possibly be expected to get her child to an important medical appointment at UCSF?”

Hannah reports that the program is effective because everyone is committed to helping the patient. “Our clinicians, medical assistants, and front office staff often pick up on what might be perceived as a subtle, but critical, need.”

Patient connections made from August 2016 – February 2017 include:

  • 150 referrals for housing
  • 130 rides to medical appointments
  • 80 connections immigration, housing, & legal services
  • 80 enrollments in health insurance & government benefits
  • 80 arrangements for rental & emergency financial assistance and materials
  • 50 referrals to health and wellness programs
  • 35 connections for employment & vocational opportunities

Martina’s and Zewidoat’s Stories

Martina Ramos and Zewidoat Temam stories may be different, but they have two things in common: both have had difficult lives – and their lives have become better because of the Patient Care Navigator Program.

Thirty-seven years ago, Martina (now 64) came to the Marin from Guatemala to escape domestic violence and civil war. She left her six children behind and came here seeking safety and financial stability for her family. Within a few years, she found work at a dry cleaners (where she ironed for 32 years), and eventually brought the children to the US. Today, she is an active participant in San Rafael’s Canal community, has ten grandchildren – and is proud to have recently become a naturalized citizen. However, she is unable to work due to a workplace injury and other medical conditions.

In 2002, Martina became a Clinics patient. Recently, she met with Elizabeth Horevitz, LCSW, to address vertigo and insomnia, which stemmed from anxiety around financial problems. She was referred to the Patient Care Navigator Program and also enrolled in the Stress Reduction program, with great success.

Hannah has since enrolled Martina in Medi-Cal and CalFresh (accompanying her to the agencies to translate and advocate) and is arranging for Social Security disability coverage and rental assistance, neither of which are easy processes. When Martina’s shoulder pain became unmanageable, Hannah found an organization to donate a rolling backpack that Martina regularly uses– including for her visits to the Clinics’ Health Hubs.

How has the Patient Care Navigator Program made a difference Martina’s life? “Without Hannah’s help, I would have stayed really sad, because there was no one to help me,” she explains. “My kids are always busy, and all my friends have said that God has blessed me by putting her into my life, especially since I can’t read. She is consistent, helps me as much as possible, and treats me with respect. It was beautiful that we met. I am really appreciative.”


Zewidoat, a single mother of five girls (ages 11 – 18), is passionate about her experience with the program. Born in Ethiopia, she came to the US five years ago. Life in Ethiopia had been challenging; it was hard to make ends meet, her mother had passed away from cancer, and she herself became bedridden.

“Life was not good,” she says, so she left the children with her brother (who later died), came to live with her son in Novato, and found work at a grocery store. She planned to bring the girls over, but it took several years, due to devastating visa problems.

Once the family was in the US, Zewidoat felt lost. She struggled to find housing, clothing, and schools for the girls, and needed to find a way to address family health issues. Living in Novato, she learned about Marin Community Clinics. Dr. Eric Schten became her primary care physician and Dr. Tracy Hessel the girls’ pediatrician. Arrangements were made for specialty orthopedic care at UCSF for one of the daughters, but more help was needed.

“When I took the children to Dr Hessel for their vaccinations, she asked me how I was doing. I told her life was hard, coping by myself.” Dr. Hessel recognized there were likely a host of needs, and referred Zewidoat to the Patient Care Navigator Program.

Once Hannah entered the picture, things started falling into place. With her assistance, they enrolled in health insurance; furniture, clothing and toys were donated by various charities; the girls were enrolled in school; rental assistance and housing support was obtained; they began going to the Health Hubs ; and, transportation to other providers was arranged. Hannah also connected them with an Ethiopian cultural center in the East Bay as well as the local non-profit Refugee Transitions for English Language Learning.

Today, Zewidoat works at a local gas station and communicates with Hannah on a weekly basis with the help of a translator on the telephone. ”It is difficult to express what she has done for us,” says Zewidoat. “She has been key to everything,” reports Zewidoat. “She is always willing to help and always kind. I consider her a member of our family. She is our caretaker.”