Leni is one of our Registered Nurses who specializes in helping those patients who require chronic care. Unlike a nurse that you might see for one shift, or a few days, nurses who care for people living with chronic diseases spend more time with their patients, and have the opportunity to build relationships.
The PCN’s chronic care nurses are system navigators – as likely to get you a referral to a dietitian or foot care specialist, as they are to recommend a class on quitting smoking, or to figure out where you can go to get your lab work done. They are experts at guiding you through the maze that is our health care system, to ensure the best health outcomes for you.
Chronic care nurses work closely with family doctors around the preparation of chronic care plans, and regularly review medications.
Like Leni says, “We are the connectors. Patients might need us to phone public health or Home Care, and then the doctor needs to be updated on those discussions.” She says that chronic care nurses are “the coordination piece – here to assist you in figuring out health resources in your community.”
Leni's enhanced training, experience, and scope of clinical practice gives her insight into what her patients require. She is instrumental in providing the extra care needed for her patients with chronic disease like congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, atrial fibrillation, type 2 diabetes, stroke, chronic wounds, or general chronic disease.
Through use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, she helps ensure the best possible medical outcomes.