“I vowed that no one under my caseload is going to have a “satisfactory” discharge plan. I will go to all lengths to ensure that there is a safe and exceptional discharge plan suitable to that patient’s and family’s needs.”
Bev Swan, Discharge Planning Coordinator, Indigenous Health
NationTalk: Shared Health Soins Commun – Bev Swan and Jason Swan aren’t just cousins, they are also Winnipeg’s only Regional Discharge Planning Coordinators, a role unique to the Indigenous Health program.
“We support patients with only the most complex cases, those that have discharge challenges and barriers to plan for,” said Bev. “Challenges may include homelessness, jurisdictional barriers, going home for end-of-life care in a First Nations community, or anything that may challenge a discharge from hospital.”
Bev and Jason’s work is hospital-based, supporting 15-20 new Indigenous clients at Winnipeg facilities each month, and additional existing clients who need support over multiple months.
For the Swans, discharge planning for their clients goes beyond just ensuring adequate Home Care supports are in place for patients returning home. Often Bev and Jason advocate for air ambulance transportation to remote communities, help clients navigate services within the health system, track down past medical records to support eligibility for services, and request funding for clients in need of temporary accommodations in Winnipeg while they receive care.
“We leave no stone unturned, and work collaboratively with the patient’s multidisciplinary care team and many external partners to plan a safe discharge for our clients,” said Jason. “This means we may need to connect with Assembly of Manitoba Chiefs, work with Northern Connections Medical Centre, and look at community programming, like Community Living disABILITY Services. We truly exhaust every avenue.”
In many cases where discharge is not suitable back into the community, a number of steps are required to support relocation for a patient within Winnipeg to ensure they still have access to the services they need during recovery.
“It’s our job to help demonstrate medical need for relocation support when it is not yet suitable for a patient to return to their First Nations community,” said Jason. “In those cases, we work closely with the hospital-based team, including physicians and allied health workers, to gather all required clinical information and then with the First Nations and Inuit Health Branch medical transportation services referral unit to determine eligibility.”
Discharge Planning support doesn’t end there.
“Once approved, we then work with external resources and help the patients and their families get settled in the community,” added Jason. “This may include support for family, registering them on Family Doctor Finder and coordinating medical appointments through Northern Connections Medical Center. Sometimes we help them apply employment insurance assistance if they were employed and secure school placement for children.”
Jason’s passion for this type of work began long before his career with Indigenous Health in 2009 and has influenced his career choices over the years.
“I started out filling a one-year term as a centralized support worker and never left,” he explained. “I moved into an interpreter resource worker position before applying for this discharge planning coordinator opportunity. Today, I’m sitting here in my own office and looking at all the thank you letters I have received over the past 15 years and thinking ‘I am blessed to be here.’ I love what I do.”
Both Bev and Jason come from Lake Manitoba First Nation and grew up speaking Saulteaux (a language also known as Ojibwe). While speaking a traditional Indigenous language is not required for their roles, speaking Saulteaux has been beneficial when working with clients who grew up in a First Nations community and feel more comfortable speaking the language.
“There was a situation where a person was deemed not competent to make decisions, and I had a conversation with the individual in our traditional language. From that conversation, this person didn’t appear to have any deficits in that area, so I asked for a reassessment,” said Bev. “Over the years, advocating for patients to be assessed in their traditional language using an interpreter from the Indigenous Health program has made a huge impact.”
The complexity of each case and the coordination required to have a successful discharge can make theirs a challenging role, but Bev vividly remembers one case that continues to push her to do her best for each client every day.
“I was six months into my role, when I first met a patient that would have a huge impact on my career,” said Bev. “They told me they wanted to change their lifestyle and didn’t want to be discharged to an environment where they would be faced with the temptations of their addictions,” said Bev. “I reached out to the community, I reached out to family, I reached out to different places I thought would be a fit. I did my job, but I didn’t push hard enough. That patient ended up being discharged to a place where they didn’t want to go.”
Sixteen months later, the patient passed away. This tragedy ignited a fire within Bev and bolstered her confidence to be a stronger advocate for her patients.
“I really felt I failed this patient because I did not push hard enough. I’m still so emotional when I talk about this, because this is what drives me,” shared Bev. “That’s when I vowed that no one under my caseload is going to have a “satisfactory” discharge plan. I will go to all lengths to ensure that there is a safe and exceptional discharge plan suitable to that patient’s and family’s needs.”
With plans to retire from her role as Discharge Planning Coordinator next summer, Bev looks back on nearly 18 years of working in this role, and the impact her advocacy has had on the lives of patients and their families.
“The most rewarding days are when you hear from families about how their loved one was able to make it back home to their community to pass away surrounded by family,” described Bev. “Or the times when people come knocking on our door saying, ‘Hey, you helped me 10 years ago. I didn’t believe in myself but I’m still here. I got the prosthetic; and you were very instrumental in that.”
“Sometimes the work can be challenging, and this job requires a lot of patience and a lot of emotional and mental strength, but sitting here in my office, I see the thank you letters I’ve received over the years, and I know I’ve made a difference. I already know I want to retire as a Discharge Planning Coordinator,” adds Jason.
Indigenous Health supports the development and delivery of culturally-appropriate programs and services to meet the needs of First Nations, Métis and Inuit Manitobans while informing and leading reconciliation and decolonization efforts throughout our organization. Learn more about Indigenous Health patient services by visiting Indigenous Health | Winnipeg Regional Health Authority (wrha.mb.ca).