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Navigating health-care systems isn’t easy, particularly for patients with multiple chronic conditions such as hypertension and diabetes. There are numerous forms, tests, specialists, appointments all over the city, and clinical advice that can be difficult to understand.

That journey becomes even more arduous for someone who is new to Canada, whose English skills are poor, and who is not familiar with Calgary, public transit or Alberta’s health-care system.

“I know what it’s like to tell a patient, ‘OK, you need to get a blood test,’ and we hand them a form and assume they know what to do. But if you ask them ‘Have you been to the lab before, do you understand the forms, how to make an appointment?’ those little things are not so obvious to everyone,” says Dr. Kerry McBrien, MD, a ��ݮ����Ƶ���� assistant professor and member of the  at the . She is also a family doctor.

“And then I think of someone who has two or three chronic conditions, who has to see multiple specialists, and who maybe doesn’t have the benefit of understanding our health-care system or our city.”

Suddenly those ‘little things’ become major barriers.

McBrien and her team have been working with the Mosaic Primary Care Network in Calgary to make life easier for patients, to improve their understanding of the system, the city and the community supports that can help them manage their care.

• Pictured above, from left are community health navigators Syeda Afreen and Suzanne Evanson, a third-year student in ��ݮ����Ƶ����'s Faculty of Social Work, with Rachel Clare, manager of the Community Health Navigation Services program at the Mosaic Primary Care Network, and Kerry McBrien, an assistant professor at the Cumming School of Medicine who helped develop the program.

With Mosaic, McBrien and the Interdisciplinary Chronic Disease Collaboration have developed a Community Health Navigation program in which ‘navigators’ assist patients with two or more poorly controlled chronic conditions: diabetes, hypertension, chronic kidney disease, heart diseases, Chronic Obstructive Pulmonary Disorder (COPD), or asthma.

Along the journey, community health navigators help these patients with everything from filling out forms to getting to their appointments. Often they will accompany patients to appointments to facilitate communication with care providers and, in some cases, translate the meetings.

Navigators help patients source everything from socialization programs at local community centres to exercise classes — in some cases, they have taken classes together. If diet is an issue, navigators can connect people with the Food Bank, or tag along on trips to the grocery store to teach patients how to stretch their dollars for more nutritious meals.

“They might help someone fill out social assistance forms — it’s about empowering people for better self-care and health, so there are many ways that can happen,” says McBrien.

Ideal navigators are people who are from the community with shared experience. They do not offer clinical advice.

The program began as a pilot project with 27 patients at two clinics within the Mosaic Primary Care Network and in June 2018 expanded to 10 clinics, largely in northeast and southeast Calgary.

The work is being evaluated through a study called ENCOMPASS (ENhancing COMmunity health through Patient navigation,��Advocacy and Social Support).

“We hear sometimes this is a service that shouldn’t be needed, but we’re a ways off from that Utopia,” says McBrien. The system, she adds, is complex and sometimes confusing, “and having someone there to walk you through it is really valuable.”

Thanks to  and nearly $1.5 million in funding through the , the program is expanding.

“As a university, we’ve prioritized engaging our community to identify areas where our researchers can make a beneficial impact,” says Dr. André Buret, PhD, interim vice-president (research) at the ��ݮ����Ƶ����. “I’m pleased that the support from Alberta Innovates will allow Dr. McBrien to expand the program. This type of platform has the potential to revolutionize the way we access health care, in no small part because it is focused on the people who use the system the most.”

The funding will allow McBrien and her team to test the model in other primary care networks outside northeast and southeast Calgary to better understand the program’s effectiveness and whether it can be scaled across Alberta.

Kerry McBrien is an assistant professor in the departments of Family Medicine and Community Health Sciences in the Cumming School of Medicine.