Ms. Penn is an RN Nurse Navigator in Primary Care. She's an advocate for the Veteran population and believes that Veterans deserve respect and special attention; she ensures that these aspects of care are carried out throughout Primary Care.

Ms. Penn recognized the immediate attention that was needed for one of our Veterans in Primary Care and jumped into immediate action to help assist the Veteran and ensure that he received the care that he needed. Ms. Penn saw a Veteran who came in as a walk-in toward the end of the day in Clinic 2 (Lonestar Clinic). She immediately saw the Veteran and soon found out that he had wounds to his bilateral lower extremities, she reported this to the PCP, and it was recommended that the Veteran should see Dermatology and a consult was placed with this department. She decided that she would call Dermatology to see if the Veteran could be seen the same day instead of having an appointment scheduled for a future date. Fortunately, Dermatology agreed to see him, and he was escorted to that department. Dermatology made recommendations for a treatment plan (topical medications) and also recommended that the Veteran see Vascular and have ABI studies done. These consults/orders were placed by the PCP the same day.

One week after seeing the Veteran in clinic, Ms. Penn made sure to follow-up on the consults and orders that were placed. She noticed that his ABIs were scheduled, but Vascular was not scheduled. She called the patient and encouraged him to contact Vascular to schedule this very important appointment. She also asked him to come into the clinic after his scheduled ABIs so she could reassess his wounds. Upon return to the clinic, she immediately noticed that the condition of his wounds greatly deteriorated since he was last seen in the clinic. It was decided that he should be admitted directly to the hospital for treatment. Ms. Penn assisted with this admission.

Upon his discharge, Ms. Penn was sure to contact him to have him come in for a post-discharge visit. He advised Ms. Penn that he was doing well, getting wound care done at home, by home health, and would come in for his post-discharge visit. The Veteran came in as promised. His wounds were improving, and he seemed in good spirits. Ms. Penn encouraged him to come in as a walk-in if anything arises that he would need assistance with. He agreed to do so, and approximately 6 days later, he came back to the clinic. The Veteran stated that his brother said he could no longer have his wound care performed in his home (the Veteran lives with his brother and sister-in-law). He stated that his sister-in-law did not want the nurse coming into the home due to the increase of COVID cases locally at the time. He stated that he was allowed to do the wound care on the porch, but the Home Health Nurse noted that she could not perform the wound care outside. Ms. Penn discussed the issue with his PCP and suggested that the Veteran should come into the Clinic 3 (Space Clinic) times a week for wound care to be performed by Ms. Penn; and for the Veteran to be educated on how to perform self-wound care so he could perform the task at home without the assistance of a home health nurse. His PCP agreed with this plan, as well as the Veteran.

The Veteran came into the clinic for a total of two weeks for wound care and education. By the end of the 2 weeks, the Veteran was able to successfully perform his own wound care and continued to do wound care at home while being followed by the wound clinic. Since then, the patient’s wounds have healed, and he continues to be followed by wound care periodically to ensure there are no changes in his condition. This event demonstrates how different members of an interdisciplinary team need to be involved in a patient’s care to ensure that the most appropriate treatment plan is developed. By working as a member of the team, Ms. Penn was able to collaborate with other disciplines (PCP, vascular, dermatology, home health, and wound care) to ensure that the patient’s needs were met. Ms. Penn’s open communication and empowerment to voice concerns related to this Veteran were all part of the dynamic that led to the best possible outcome.

Ms. Penn also demonstrated the importance of assisting Veterans without a stable support system at home to ensure that their needs are met. By providing the Veteran the opportunity to come to the Primary Care Clinic to have wound care performed and by providing self-care education, the Veteran was able to have a positive outcome. Ms. Penn also confirmed how important close follow-up is for positive patient outcomes. Close follow-up made by Ms. Penn was vital to ensure that the Veteran received appropriate follow-up care and treatment, thus preventing the likelihood of the Veteran being readmitted to the hospital due to complications.