Team assesses patients’ needs in their homes

As a personal care nurse, Rosalyn Watson built a long and successful career out of helping others. But when the Calgary senior developed health problems of her own and was forced to take a leave of absence from her job, she felt overwhelmed and turned to her family doctor for help.

Dealing with chronic dizziness, a lack of mobility and financial and personal stress as she waited for head and neck surgery, she was referred to the Calgary Foothills Primary Care Network’s Navigation Team by her physician.

1. Community support worker helps patient

Community support worker Dayra Bello, a member of the Navigation Team, visited Rosalyn at her home. After making a detailed assessment of her needs, Dayra spent the next month helping Rosalyn access resources to improve her quality of life.

“There were so many things she was dealing with,” Dayra says of Rosalyn. “Due to her lack of mobility she was isolated and unable to access medication or the help and support she needed.” Dayra connected Rosalyn with the Calgary Seniors’ Resource Society and she was accepted into the Escorted Transportation program.

During follow-up appointments, Dayra also helped her to access income support. “The Navigation Team helps the patient to access the resources they need to deal with the challenges they face,” Dayra says. “This time it was social work but it could be mental health, geriatrics, health education and so on.”

2. Team helps patients with health and social issues

The Navigation Team focuses on providing comprehensive assessments and resources for patients with cognitive impairment and those who are at risk of falls, coping with a life transition or in need of a home safety assessment. In part because the team is mobile, it has a unique ability to act as the “eyes and ears” of the Health Home, the doctor’s clinic, during home assessments – and get to the heart of an issue.

Rosalyn had successful head and neck surgery and is now awaiting knee surgery. “I was so happy to meet Dayra. I had been trying to cope by myself and I was having a lot of trouble just standing up,” she says. “She encouraged me to get help. If she hadn’t come to visit I don’t know what I would have done.”