Hospital to Home: Nurses Help Navigate Their Patient's Recovery

Hospital to Home: Nurses Help Navigate Their Patient's Recovery

The content provided focuses on the innovative approach of a hospital creating a nursing program to support patients recovering at home. Specially trained nurses engage with discharged patients for 12 weeks, ensuring medication adherence, follow-up appointments, and providing health coaching. This initiative aims to reduce readmission rates and ER visits significantly. Kathryn Moore, a nurse liaison, exemplifies personalized care, understanding Tom's priorities, notably his annual fishing trip. The program is part of a larger initiative training nurses on post-discharge transitional care management, involving over 430 nurses since 2017.

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This narrative showcases a hospital's pioneering nursing program aiding patients in post-discharge recovery at home. Specially trained nurses provide personalized care for 12 weeks, ensuring medication adherence, follow-up appointments, and health coaching. The initiative, aimed at curbing readmission rates and ER visits, demonstrates success with a 50% reduction in readmissions and a 60% decrease in ER visits. Kathryn Moore, a nurse liaison, illustrates the program's efficacy by understanding and supporting a patient's desire for his annual fishing trip. This initiative is part of a comprehensive program training over 430 nurses in post-discharge transitional care management since 2017.


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