Staff registered nurse and care coordinator
Research has shown that patients have a better experience when they have a health care navigator to guide their journey. By helping patients better understand health care, a navigator can eliminate many obstacles and frustrations of a long-term medical condition.
As an ambassador of patient-centered care, Marty Castillo, RN staff nurse and care coordinator, does just that. She establishes a therapeutic relationship with the patient and their family, collaborates with the entire rehabilitation team, collects and shares information between disciplines, and organizes the overall provisions of inpatient care. The care coordinator adds a layer of support between caregivers and patients, which improves overall accessibility. After a 2009 pilot, the program was expanded to include four care coordinators at Aurora St. Luke's, one at Aurora Sinai, and one at Aurora West Allis.
On an average day, Marty meets new admissions within their first 24 hours of care, identifies contact people, verifies medical information, and establishes basic information about the home environment. She also conferences with physicians and other members of the rehab team to set goal discharge dates for each patient, based on their recovery and progress. She meets with social workers to help coordinate the transition from inpatient to outpatient, and makes follow-up phone calls to patients 48 hours after discharge to ensure their needs were met.
"Many times, we are the ones called upon to make the impossible possible," shared Marty. "And somehow, we make it happen." In Steve Hofmann's case, Marty arranged for his dog to be incorporated into his therapy. "He was really missing home, and seeing his dog again meant so much to him. And by walking, talking and playing with his pet, he was doing something that he loved and healing at the same time."
"I always remind myself that each person is their own self," shared Marty. "They are a person with their own opinions and emotions; they are somebody with hopes and dreams. We only know them as who they are now, and sometimes it's hard to mesh who they were before. But we need to remain fair and true to the patient. It's our job to find out who they are, no matter how difficult that could be. I feel rehabilitation is all about understanding the whole picture. It's not about can you walk, talk or swallow your food. It's holistic. It's your whole life. And our job is getting you back there."