Back in 2023, as Richmond, VA resident Edna lay in her hospital bed, she couldn’t help but feel overwhelmed. She historically had struggled to stand up for herself in healthcare environments and couldn’t imagine dealing with that stress so soon after the stroke that had sent her to the emergency room. 

“It wasn’t the first time I’d been to the hospital,” she added. “I was also being treated for heart failure and seeing a lot of specialists too. There was a lot going on and it was really hard to manage.”

And then, Edna continued, a new visitor showed up: a gentleman in a black collared shirt who introduced himself as Charlie from Waymark.

“I was a little skeptical at first,” Edna said. “I didn’t know what was going on and I’d never had anything like this before. But Charlie made me comfortable, and it was like we’d known each other all our lives.”

Charlie McCarson, one of Waymark’s senior community health workers, had seen Edna flagged as a rising risk patient via Waymark Signal™ – Waymark’s proprietary tool that identifies patients at increasing risk of avoidable hospital and emergency department visits, integrates social determinants of health data and uses data science to help team members provide care. He explained that he was here to see how he and other members of Waymark’s care delivery team could support her.

“I think it’s a common feeling,” Charlie said. “If I were sitting in the hospital and someone rolled in that I’d never seen before offering to help me, I’d be a little weird about it too. But I’m glad you let us be a part of this.”

Edna said she was used to seeing healthcare workers come in and out of her hospital room, but what stuck out to her about Charlie is that he came back and visited multiple times between when she was admitted and discharged.

“I thought that was really nice,” she said. “It made me feel real comfortable with him.”

Empowerment Through Education and Advocacy

When Charlie asked Edna what her goals were as she partnered with Waymark, she had them on the tip of her tongue: “I want to be more active in my community, I want to stand up for myself more with doctors, and I want to be less shy when I’m talking to people.”

As Waymark Licensed Therapist Mironda Womack connected Edna with a psychologist to begin working on her social anxiety symptoms, Charlie and Edna began tackling the first priority on Edna’s way to more community engagement: housing.

“She’s on the second floor, but due to a visual impairment, her doctors want to see her on the first floor,” Charlie explained, as Edna was at high risk for a fall. “So we worked together to get on the waiting list for a unit on the ground level.”

“It’s hard to get out into the community when I can’t get down the stairs or into the elevator,” Edna added. “But I’ve been trying more, and getting in-home help was real helpful. "

That was the second item on Charlie and Edna’s list; Charlie knew how to support Edna as she worked to connect with an in-home health aide who could assist her with tasks that were taxing or difficult.

“He also helped me find some social connections so I could work on my shyness,” Edna added. “And he connected me with Meals on Wheels and all these other things I didn’t know how to find by myself.”

In addition to connecting her with Mironda, Charlie also reached out to Jeffrey Tingen, Waymark’s Clinical Pharmacist Lead in the Richmond area, to start a conversation about managing Edna’s type 2 diabetes. When Edna and Jeffrey met for the first time, she had been checking her glucose levels by pricking her finger – but Jeffrey was able to offer her a more high-tech solution.

“He got me one of those CGMs (continuous glucose monitors) and now I just have to open my phone to look at my levels,” she said. “And I don’t have to prick my finger anymore. … That’s really, really improved my life.”

 “I was really glad Edna spoke up so I could help her find a solution,” Jeffrey added. “I’ve actually been able to spend time with her to answer medication questions and help her understand what her doctors are prescribing and treating her for, especially since she mentioned she gets overwhelmed sometimes with so much information while in the actual doctor’s office.”

Through it all, Edna was able to hone her self-advocacy skills, she said. She visits multiple doctors regularly to manage several chronic health conditions. While she previously struggled to communicate with them, now it’s a different story. Since starting to work with Waymark, she’s felt supported by her care team as she advocates for herself and how she prefers to manage her care.

“I didn’t want to use a needle to manage the diabetes, so we worked out another way to do it,” she said. “I used to be depressed, but I’m not anymore. That’s because I have Charlie and Jeffrey in my life to help me figure out how to get what I needed.”

Moving Toward New Goals

Charlie jokes that Edna liked Waymark so much she came back for more; she graduated from Waymark for a time when her insurance changed, but when she was once again enrolled in an insurance program that was eligible for Waymark’s services, she was thrilled to pick up right where she and Charlie left off.

“There was a lot of growth, and there has been even more growth,” Charlie said. “When we met, there were a lot of specialists in the mix, and Edna’s got really great at managing all of them throughout the time we’ve worked together.”

Since starting to work with Waymark, Edna’s made many strides toward her other goals as well. She’s begun studying to become a Jehovah’s Witness and said her work with Mironda has made her feel confident standing up and speaking during a meeting – something she would never have done a year ago.

“I can remember what I’m saying and I don’t get shy,” she said. “Even if I’m nervous, it feels like a normal nervous now.”

She’s also become far more confident in her own capacity to manage her healthcare. Where before she wasn’t always sure how to ask doctors for what she needed, or how to find a tool or resource, now she feels empowered to take ownership of her health and care – knowing that Waymark’s care team has her back.

“Charlie and the rest of the team, they know where and how to help me find the tools and people to manage my health,” she said. “The impact on me is from them working with me and making sure things got done. With Waymark, I feel like I’ve accomplished a lot compared to where I was.”