Calling to check in on "Adriana," a patient who had recently given birth via C-section, Evolent RN Health Educator Yuneysi Diaz was concerned from the start. The patient had clear signs of post-cesarean wound infection, but she was not planning to have a physician examine it.
"I realized how alone she was in her situation," recalls Yuneysi. "The patient had other children in her household and had no caretakers or income, which set off a red flag for me. Because so much was going on, I worried she might put her health second."
Yuneysi helped Adriana get back in touch with an in-network OBGYN who had worked with her during her pregnancy. This provider referred Adriana to the hospital and prevented the serious infection from becoming septic and life-threatening. After two nights in the hospital on intravenous antibiotics, Adriana was discharged.
While Yuneysi had helped Adriana avert potential disaster, she remained uneasy. The obstacles that had initially kept Adriana from going to the doctor might contribute to additional health problems for the mother and child. Yuneysi arranged to visit Adriana at her home.
As her home visit progressed, Yuneysi quickly learned there was more to this patient's story than postpartum complications. Adriana opened up about her challenges as a divorced, immigrant mother raising multiple children while cleaning homes and businesses on a meager income. Adriana worked hard at this job up until the day she delivered her most recent baby, at which point she could no longer work and relied solely on a small income by her 21-year old daughter. This most recent pregnancy was the first time Adriana was really asking for any assistance.
Yuneysi answered this call for help, starting with a referral for a behavioral health counselor to conduct home visits with Adriana. Yuneysi also helped Adriana apply for government programs including SNAP (for food assistance), LIHEAP (for electric bill assistance), child-care assistance and unemployment. Adriana became both aware of and grateful for these community resources available to her family.
With Yuneysi's support, Adriana graduated from Evolent's care management program better equipped to manage her and her family's physical and financial health. Adriana was able to secure a more fulfilling job working with senior citizens—a position that offered her better pay and steadier hours to be home with her children. Yuneysi also referred Adriana's older children to a job-training program for high school graduates.
Yuneysi is glad she heeded the warning signs and met the family in person.
"Sometimes you underestimate the importance of having a conversation and really getting to know your patients to make a difference. [Adriana] was able to trust me, and because she trusted me, she was able to follow my advice."