Healthcare: Navigation, Education & Advocacy

Healthcare: Navigation, Education & Advocacy
0 December 4, 2015


eorge was 83 when he was admitted to hospital on Christmas day with dehydration, weakness and confusion after spending the three previous days experiencing flu-like symptoms. Three days after being admitted to the medical-surgical unit, George was diagnosed with pneumonia, moved to a private room and put under isolation. This limited his social contact and mobility.


A family member remained with him as much as possible, trying to get an understanding of what the next steps would be. With nursing shifts changing and different doctors coming in and out of the room at different times of the day, no one seemed to have an answer for the family.


Four weeks passed and George had improved, the pneumonia cleared and he was moved to a semi-private room in the infectious disease unit. He was unable to go home because a pacemaker was inserted as recommended by the cardiologist, but fear prevented the family from asking for an explanation of its necessity.


By February, George had been in the hospital for 6 weeks. The family were stressed and heard mention of dementia but were not given any explanation. George’s kids wanted to be at the hospital to have the opportunity to discuss discharge plans. This proved to be difficult with the family not knowing the doctors’ schedules.


George’s daughter Nancy and her siblings were getting pressure at work for taking time off to be at the hospital. Nancy talked to a friend and explained the situation, and the confusion and frustration being experienced by the family. Nancy’s friend suggested that she call an RN that she knew in independent practice, specializing in helping families with healthcare navigation, education, and advocacy.


After discussing the families goals and objectives with Jana, the health care consultant, the family wanted George moved back to the retirement facility he had resided in with his wife before he was admitted to the hospital.


Jana met George, and his wife and kids at the hospital he was admitted to. A family meeting took place to discuss how she could expedite the discharge process and what that would entail.


With the consultant’s expertise in hospital discharges, she was able to facilitate a seamless transition from hospital to home, with adequate home care services arranged.


Three days after discharge the consultant and Melissa, a certified Geriatric nurse, visited George and his wife at home to make an assessment. George presented in good spirits, however was unsteady and disoriented. A medication review led to the discovery that the combination of two of his medications was the underlying factor in his unsteadiness. Melissa, who specializes in Alzheimer’s and dementia, determined that George was suffering from 4th stage dementia and was in need of a Geriatrician. She was able to discuss and educate the family on dementia and answer all of their questions.


George is currently living with his wife in their retirement facility. He is steady on his feet and being monitored for dementia. Home care comes three times a week to help with housework. George’s wife and family cannot believe the improvement, considering that at one point they thought George was going to die.


The importance of educating families on what they are faced with cannot be overestimated. Knowing the options for treatment and feeling empowered to make informed choices is paramount to one’s health journey.


Submitted by Jana Bartley RN, BScN, MBA, LNC


Jana has built a team of specialized registered nurses who are dedicated to navigating the healthcare system for their clients of all ages. In person services are offered throughout the GTA and virtual support is offered nationally.


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