EHN 2022AnnualReport 9DIGITAL - Flipbook - Page 20
Improving patient outcomes
Dedicated nurse care managers partner with primary care providers to
support patients with one-on-one outreach—proactively addressing a
patient’s health care needs and identifying any potential issues based
on personal family history or existing chronic conditions.
Moving from tractor to scooter
Last June, Eastside Health
Network (EHN) Ambulatory
Care Manager Riaz Kanji
began working with an
elderly man who had
memory issues and was
having trouble with falls.
Because of the memory issues,
Riaz was unable to speak directly to the patient,
so he first began conversations with the patient’s
daughter-in-law. With the Primary Care Provider’s
permission, Riaz sent outreach to the daughter-inlaw. Riaz began the process of obtaining a release
from the patient. (The release would allow Riaz
to discuss patient health details with members
of the family.)
In the meantime, Riaz could not share any health
details with the daughter-in-law, but she was free
to share with Riaz.
The patient lived with his 90-year-old wife across
a field from his son and daughter-in-law. He was
unable to walk and was wheelchair bound, but he
would travel to his son’s house on a tractor.
From talking to the daughter-in-law, Riaz assessed
that this family needed home caregiver assistance.
A daughter who had medical background was doing
most of the caregiving for both the patient and his
wife, who had her own health issues. Riaz spoke to
this daughter who expressed feeling overwhelmed.
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Still waiting for a signed release, Riaz was able to
speak to the patient’s wife who assured him that
they were doing just fine and did not need any
outside help. Riaz pointed out that the daughter
felt overwhelmed. The daughter joined the phone
call with Riaz and the mother and echoed the
mother, saying everything was just fine. Riaz
realized there might some family dynamics at play
in this situation, too.
Riaz did a referral to EHN Social Workers, who
would be able to connect the family to any
resources they would accept and would be better
equipped to unravel any family dynamics.
Release paperwork was completed after about two
months. In the meantime, the patient was admitted
to the hospital with a new diagnosis of Atrial
Fibrillation. Luckily, Riaz and the patient soon had
a professional caregiver in place. The professional
caregiver was able to help the patient and give the
daughter relief, improving her own health.
The patient’s health even improved to the point that
he could often use a cane at home, instead of being
entirely confined to a wheelchair.
Riaz was particularly excited about his work with
this family he empowered all members of the family
to meet their own needs.
And in maybe the most important marker of
success, the patient now has a scooter so he can
move across the field without firing up the tractor.
EASTSIDE HEALTH NETWORK