In NNSI’s #SystemsofCare series on referral networks, we have described the different technologies that support inter-agency referrals and how organizations have implemented them. In this post, we look at the humans that make referral navigation happen. What do employees do at referral networks’ coordination centers?
In this article, we interview Hunter Russ, a navigation specialist with Veteran Services of the Carolinas. Veteran Services of the Carolinas (VSC) assists Veterans and their families in North Carolina by identifying needs and providing services, and in this interview, we focus on their coordination center. This interview can help organizational leaders gain personal insight and better understand the work behind the scenes to connect their clients with the appropriate organizations and services.
What’s your role at the Veterans Services of the Carolinas? How long have you been in the role?
Currently, I serve as the Assistant Director of Service Coordination, overseeing our NCServes program. I’ve been with VSC since September of 2019. I started as the Senior Care Coordinator and have since been promoted to my current role.
Describe your typical day.
I check the system to see what is going on, follow up on any remaining tasks or emails that still need attention and then connect with the Coordination Center team for a brief breakdown of the day or what they are working on. After getting settled and checking on the team, if needed, we’ll strategize about any difficult client situations that they have run into or are still trying to find solutions for. We will make the necessary connections for that client (i.e., call local crisis ministries, the Veterans Administration) to help get the information we need or determine eligibility criteria before sending a referral.
After we connect about these clients (which happens throughout the day as well), I will work on any grants that we are interested in applying for or search for grants that might be beneficial to our programs. I also search for new providers that we are not engaged with or need to be engaging more if they are already on the platform. After this research, I work to make those connections in the community and be alongside providers as they use and navigate the system.
We want to be kneecap to kneecap while engaging providers because that is where the best relationships are formed. I also make sure that the Coordination Center is running smoothly, and if they are getting an excessive amount of calls, either jump in and handle some client needs or send referrals for them to ease the workload. Each day is vastly different, and that always presents a wonderful challenge.
Tell me about what happens when you receive a request for information.
The Care Coordinator who has made the initial connection will see it through to the end of the assistance. We do a complete biopsychosocial assessment to ensure that we aren’t missing any additional needs. For example, suppose someone calls for assistance with housing and is behind on their rent. In that case, we will also inquire about utilities, change in job status or family composition, food insecurity, etc., to ensure that we are addressing the whole person’s needs. Most people are only focused on the one issue that they feel is the more important, but we want to ensure that we are looking at everything so that they will continue to be successful after receiving assistance.
What conversations happen to make the appropriate referral? How do you know which referral is best?
As a team, we try to stay connected with our providers regularly. We have established each Care Coordinator to be a Service Area expert, with each focusing on a few of the 21 social determinants of health in our coverage area. Everyone can do a housing referral, but we have someone who handles the more difficult situations or the ones that need some more work. We regularly connect and discuss clients across the team to ensure that we are not missing any essential information or eligibility criteria. We make sure that the Veteran is a good fit for the program or the service before sending the referral. We want to ensure that they’ll be able to be successful on their own after being connected with the organization or program and receiving the assistance they are seeking. If they aren’t a good fit for that particular program, we work to divert to a better community resource.
We also make sure that we are not over-sending referrals to community partners to ensure that we can maximize community funding. For example, if someone needs assistance with a $400 power bill, we won’t send a referral for the total amount to one organization. We may send it to three or four (or more if necessary) organizations to ensure that the community can support as many people as possible. We try to make the pledge connection as simple as possible for clients and partners.
What happens with the information after the referral?
We will follow up on that referral within a few days or a week, depending on the type of referral. During that follow-up, we make sure that they received the initial assistance they asked for or determine if we need to continue seeking out community resources for them. VSC also has an 18-month follow-up for all participants across all four programs, including NCServes. Throughout that time, we will regularly follow up every 2-3 months to ensure that no need or request has been missed. We do this because we know that life changes and situations arise.
What do you like best about your job? What’s the most challenging aspect?
I like that each day is different and at the end of the day, knowing that the work that my team and I do genuinely makes a difference in the lives of those we serve. As a veteran’s spouse, I know the impact of our work and how much it means when one of your own is there to support your struggles. The most challenging aspect can be figuring out solutions for the tough situations that we are presented with, the ones where they have exhausted all resources and don’t have anyone in their corner. We get to step in and figure out how to be a champion for them and get them connected to the best provider for assistance.