K.H. retired from a stressful but fulfilling job. He had always been a fit man who worked hard to support his family. He played guitar professionally and has a deep spiritual faith. However, his children feel ‘eha (distress) at the
K.H. retired from a stressful but fulfilling job. He had always been a fit man who worked hard to support his family. He played guitar professionally and has a deep spiritual faith. However, his children feel ‘eha (distress) at the thought of all the suffering their father has endured due to his advanced heart failure.
Because of his heart disease, K.H. has a pacemaker. This medical device will help prevent sudden death from an irregular heartbeat by shocking his heart back into a regular rhythm.
K.H. recently was rushed to the hospital after being thrown off his feet by a shock from his pacemaker. For K.H. and his family, it was a priority to understand in greater detail why the pacemaker shocked him.
A registered nurse care manager visited his home and provided additional education about heart anatomy and function, pacemakers, medications and risk factors that can aggravate a heart failure condition. Empowered by a deeper understanding, K.H. has determined achievable steps toward improving his overall health.
The RN was able to help K.H. through an innovative pilot program called the Best Heart Care Project. Creating a network of care to effectively manage chronic heart disease patients is a priority initiative of Community First and the Regional Health Improvement Collaborative. Partners in the initiative include the East Hawaii Independent Physicians Association, Hilo Medical Center and Hospice of Hilo.
Effective patient education and symptom management often can decrease the incidence of disabling events and suffering associated with heart failure. At the heart of the program is care management. RN care managers act as readily accessible, skilled and licensed resources for individuals who are at high risk for poor outcomes due to complex health needs. The goal is to have meaningful relationships with patients which help them to manage their care for the best outcome.
Although the pilot project is small, it is making a difference in our community.
S.A. is an active man with a thriving business and a loving family. But S.A. has had four hospital admissions in two years. The first three were for severe joint pain and infection due to a chronic systemic disease that he battles to control with medications and diet. This disease placed him at a high risk for damage to his heart. Then, in February 2016, S.A. was rushed to the hospital for the fourth time, but this time was different. He had difficulty breathing and his heart was racing uncontrollably. S.A. was diagnosed for the first time with heart failure.
Just two weeks after meeting the RN care manager, S.A. called to say his right arm had become painfully swollen in three days and he could not move it. He wondered if he should go to the emergency room. Fortunately, S.A. had called early enough that the RN care manager was able to help S.A. coordinate transportation and an urgent visit with his primary care physician that afternoon. The problem was effectively resolved and S.A. gratefully avoided a fifth hospital visit.
A.M. is a vibrant woman with a devoted husband and a large network of caring family and friends. After a lifetime of helping her husband run his farm and manage responsibilities at home, A.M. found herself last year with swelling in both her lower legs. Despite following doctors’ orders, A.M.’s legs developed an infection that would not heal. It seemed to rapidly progress, and one day just a few months after it started, A.M. found she could not walk. She was admitted to the hospital for the infection only to discover she had a new diagnosis of heart failure.
A.M. and her husband have had a longer road to recovery than expected. Throughout the months that followed her hospital admission, the RN care manager has been able to support and coordinate care transitions from the hospital to a rehabilitation facility and finally home where she is now back in a comfortable routine.
Although their stories are unique, a common thread is the potential for devastation caused by heart failure. In each case, the RN care manager became a member of their health care team. This kind of care management has proven to improve quality of care and lower costs in other communities. Community First is trying to bring those benefits to East Hawaii. These early successes are steppingstones to an effective, sustainable health care system for our entire community.
Tony Kent, MBA, is the community engagement coordinator for Community First. He worked closely with the RN care manager to tell these patients’ stories.
This column was prepared by Community First, a nonprofit organization led by KTA Super Stores’ Barry Taniguchi and supported by a volunteer board of local community leaders. Community First was established in 2014 to help the community respond to the health care cost crisis and support initiatives that change health care from just treating disease to caring for health. To learn more about Community First, visit CommunityFirstHawaii.org.
