On any given work day, Karen Maletich may be calling patients recently discharged from a hospital to check on their status. Or she may make home visits with patients who have complex health care needs. Maletich is a nurse navigator with San Juan Basin Public Health. Along with three colleagues, she coordinates care and connects clients with resources they need to support their health. The work is funded as part of Colorado’s Region 1 Regional Care Collaborative Organization, and every day is as varied as the individuals she serves.
Maletich previously worked as a nurse in a long-term care setting. She has served in her current role for nearly six years.
“I started as a nurse navigator for seniors because of my background,” she says. “I have always been drawn to working with seniors, but when I worked in long-term care, I really didn’t have the time to spend with my residents that I wanted. As a nurse navigator, I can go to seniors’ homes, sit down with them and get to know them.” Maletich’s patients now include people of all ages, and she says she values the time she can invest in each person.
Every six months, the team is responsible for fully assessing a range of health care needs for about 500 local residents who are dually-eligible for Medicare and Medicaid. Those who need assistance receive a customized plan of care and more frequent contact.
“We try to do those assessments in person, although if they prefer it, we can do it over the phone,” she says. “One of the main things we do is connect people to resources. We look for unmet needs, and we try to help fill those.”
Those needs may include a referral to a food bank, transportation to a medical appointment or a range of services that address social and behavioral health needs. Maletich will also accompany patients to medical appointments when they need help to better understand a diagnosis or treatment plan. “We visit patients in the hospital and talk to them about their concerns. We can do research for them to help them get answers to questions and access resources they need,” she says.
Coordinating care and helping patients get to specialists is a big part of Maletich’s role. “Being in a rural community presents some barriers, and one is a lack of some medical specialists,” she says. Transportation to see a specialist in Denver, for example, requires a six to seven-hour trip each way. Maletich and her colleagues can arrange transportation and check back with clients after their appointments.
“Being able to spend time with each client so I can see the whole picture has opened my eyes to the community as a whole,” she says. “It’s opened my eyes to the world. For so many people, it’s a daily struggle to be healthy because of poverty, lack of transportation, behavioral health issues and affordable housing. I enjoy the opportunity to interact with people, and I try to offer them opportunities to overcome those challenges.”
Maletich emphasizes that her community-based team offers these services as a free benefit to anyone who lives in the region. “We are a community team, so we can work with anyone; you don’t have to have Medicaid. We can take a referral from the senior center for someone with Medicare or with no insurance. We can’t solve all problems, but you can come to us with anything and we can try to help solve it, or we’ll direct you to the person who can help.
“Our goal is to assist people to live as well as they can, and it’s up to them to determine what that means, and what that is, for them.”