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From Hospital to Home

Picture this... you have recently been through a health crisis. Your family takes you to the emergency room and you’re admitted to the hospital. Over the course of several days people with hospital badges you can’t read enter your room in groups – quickly explaining in medical jargon the “plan” and exiting before you can ask questions. Your children try to be there when the doctors do their rounds, but they keep missing them. And relaying the bits and pieces of information you can remember is so difficult. Your son suggests asking your nurse to call him to explain what’s going on – but you don’t want to bother her, she seems so busy. It seems you have been diagnosed with a new health condition, are being prescribed new medications, and will follow up with several specialists outpatient.

The next morning around 10am, your nurse lets you know that you’ll be discharged within the hour. You call your daughter to let her know to come get you – but it keeps going to voicemail. The hospital discharges you to wait for your daughter in the lobby, the hospital is full, and they need your bed. Your daughter takes you to the pharmacy to pick up your new medications - but one is not in stock. The pharmacy staff tells you they have it in stock across town and have sent your prescription there. By the time you get to that pharmacy – it’s closed. You go home and try to organize the medications you are supposed to take tonight. All you can remember is that they said don’t worry about the once-a-day medications until tomorrow – but what about this one that says daily at bedtime?

You were told that the specialists would call you to set up your appointments, though after a few days you haven’t received any calls. Wait, weren’t you supposed to be checking your blood pressure every morning? Where is your blood pressure cuff? You forget to go back to the pharmacy and now you’ve missed three days of your new blood pressure medication and you start to feel the effects. You desperately want to get better but are feeling very overwhelmed, and your health is suffering because of it.


Now imagine if you had someone to help you navigate your way through the healthcare system. Someone with the expertise to coordinate with you, educate you, and advocate on your behalf – working FOR you. The RN Care Manager comes to your hospital room and introduces herself as the hospital is planning your discharge. She looks over your medical history and everything that has happened while you’ve been in the hospital. You can ask all the questions you have, and she stays until you feel comfortable with the next few steps. Then, she calls your family and does the same.

Your daughter can’t get off work at the time the hospital discharges you, so your RN Care Manager drives you home. She leaves to the pharmacy and comes back with all your new medications – and a blood pressure cuff. While she goes through your medicine cabinet of old medications, she explains which ones you still take, and why. You realize you don’t feel comfortable setting up your pill box with all the new medications, so you sit together, and she walks you through it. Together you both decide that for the next few weeks she will come every Monday to help you organize your pill box and, while she’s there, she does a complete physical assessment.

Two weeks later during your weekly visit with the RN Care Manager she notices your blood pressures have been slowly increasing, and your feet look a little more swollen than usual. She calls your cardiologist who decides to adjust one of your medications. The next day your blood pressure is back to normal! You give her a call just to let her know, and she reminds you that you have a follow-up with your primary care provider – and asks whether you want her to come with you or not. You tell her you feel confident enough to go alone – except you can never remember which medications you take and when, so she emails your updated medication list to your PCP’s office.

A systematic review from 2021 found that elderly people with complex medical conditions are particularly vulnerable to adverse events after hospital discharge and are commonly readmitted to the hospital due to poor planning and unintended events led by a breakdown in communication between hospitals and primary care providers. Transitional care interventions, such as the use of an RN Care Manager, reduces the risk of readmission – and the more hands-on the intervention is, the less likely you are to return to the hospital.

Your RN Care Manager assesses, advocates, and educates. They listen to your concerns and answer your questions – no matter how many times you have to ask. They are working in the background keeping track of your appointments, medications, and results from diagnostic tests. They can go to your appointments and help translate the medical jargon. Anytime you start to feel overwhelmed or unsure they are one phone call away. They make sure nothing falls through the cracks and stay up to date on best practices and research to ensure you are getting the best care. They adapt their care management based on your evolving needs, always with your personal goals in mind.

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