Supporting Patient Autonomy

Hello! My name is Melanie (she/her/ella), and I’m currently the Street Medicine Palliative Health Patient Navigator at the San Francisco Department of Public Health. I am a Bay Area local. I graduated from UC Irvine with a Bachelor of Science in Public Health Sciences and a Bachelor of Arts in Public Health Policy. I joined NHC SF to connect with the community that I grew up in, and I wanted to learn about the different public health work already being done here in the Bay Area. 

In my role, I am part of one of the Street Medicine clinics, the Gubbio Project, and do outreach in the Bayview District. The Gubbio Project is at a local church in the Mission District in which they provide a safe space for people to rest during the day. Street Medicine holds a clinic two days out of the week. To support the Gubbio Project, I assist a Street Medicine doctor and nurse. We see anyone that is interested in speaking with a medical provider, and visits vary from medication refills to wound care. While doing outreach in the Bayview District, I go out with a nurse and a health worker to follow up with different patients that may need refills of medication and check in with them on their path to housing. Sometimes we also transport patients to their medical appointments. 

In addition to the Street Medicine Clinics and outreach, I support the Street Medicine Palliative Care Project. The Palliative Care Team was founded by Dr. Tanya Majumder and Social Worker Melanie Bien to make transitional palliative care more accessible to seriously ill unhoused folk. Over time, the Street Medicine Palliative Care team has grown to be composed of social workers, registered nurses, health workers, and medical providers. The team provides a structure of care through outreach & engagement, clinical care coordination, and trauma-informed patient-centered care. The Palliative Care Team has around 30 current patients that we see weekly, every other week, monthly, quarterly or as needed. 

On Tuesday mornings, I log onto EPIC to review any changes in our active palliative care patients, such as admission to the emergency room or appointments with primary care providers or shelter health. This helps me know if a patient’s location and any new changes in their care have changed. Afterwards, I update the palliative care Excel spreadsheet, which includes referrals, current active patients, and overall data. Once done, I conduct outreach with one of our health workers and a medical provider. Recently, I visited a Spanish-speaking, palliative care patient who was connected with Shelter Health. I introduced this patient to our palliative care team to share who was part of the team and to determine what services can be provided. These interactions are an opportunity to see if patients are interested in our services and to answer any questions they might have. After my visit, I let this patient know that I would come back to visit again to allow them to think about whether they wanted our services - their healthcare is their choice. 

In the afternoon, the palliative care team meets together for our huddle, where we review our active patient list to provide any updates. Each patient has an assigned teamlet, a group of different palliative care team members, designed to best match the patient’s needs. Once we finish updates, we divide into groups to outreach specific palliative care patients and meet them where they are. This may be visiting the emergency room, shelters, clinics, on the streets, and when they are placed into housing. Recently, the team, consisting of a provider, a registered nurse, a volunteer, and I decided to reach out to one of our new palliative patients. This palliative patient, who is unhoused, was admitted to the emergency room, had been recently diagnosed with a severe illness, and was adjusting to recent changes and determining next steps. During our visit, we went over the discharge plan, next steps, and check-in with the patient and their emergency room provider. Together, we provided comfort and support to the patient. I further explained the options available to them and how the team could create a visit schedule to help them transition to a new location, including daily visits for the remainder of the week. The following morning, I checked in with this patient regarding their new location and updated the next team member assigned to visit them. 

Being part of the palliative care team has shown me our patients' various needs. Patients may need assistance attending medical appointments, being connected to housing resources and social services, and many other things. Our current healthcare system expects patients to be able to navigate the health landscape easily, but it fails to consider the many barriers to care. The system expects our patients to be engaged in care, yet it does not always take into account their overall goals or wishes. Palliative Care has further emphasized and taught me the importance of patient autonomy when it comes to their care.