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Enhancing Care Coordination Through Communication

Angela Zacarolli, RN, BSN

My story is about reducing hospital stays through enhanced care coordination in a patient with chronic illness. When I first met my patient, he had been recently discharged from the hospital. I noted that he had several recent hospitalizations for Congestive Heart Failure (CHF) symptoms within less than 30 days.

Quickly I discovered that his wife managed his healthcare appointments and would play a vital role in both his support system as well as maintaining contact with the healthcare team. Knowing the importance of provider office visits within a few days of hospitalization discharge, I scheduled my patient for a visit with the primary care doctor and encouraged him to keep the already scheduled appointment with the cardiologist. In addition, I also reached out to a local CHF clinic to establish a relationship for this patient, which was crucial in developing a well-rounded, practical plan to coordinate this patient’s care outside of the hospital.

As a Nurse Navigator, I focus on enhancing care coordination through communication among the various members of a patient’s healthcare team. In my patient’s case, the patient, his wife, and healthcare team all agreed that a weekly provider visit with the primary care doctor, cardiologist, or CHF Clinic with an Advanced Practice Registered Nurse would greatly assist in managing the patient’s symptoms and healthcare plan. Currently he has been hospital free for over 60 days.

Tags: Medical Home

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