Visiting Nurse Association Health Group (VNAHG) logs 60 to 100 patient referrals a day, mostly from well-established hospital partners who want to pair newly discharged patients with home-based health services.
Marie Ruiz, case manager and lead assessment coordinator at Jefferson Health Care Center, is a fierce advocate for her patients. But she doesn’t always win.
Nurse-led approach helps cut costs, spur recovery
Caring for older patients living with complex health and social needs is one of the biggest challenges for the healthcare system. It’s a challenge that will continue to intensify as the baby boom generation ages.
Mary Naylor, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, is the lead architect of the Transitional Care Model (TCM), a nurse-led approach designed to help improve the care of seniors coping with multiple chronic conditions who experience frequent episodes of acute illness. The goal is to partner with patients, family caregivers and other clinicians to improve the patient’s health and quality of life. Studies consistently show that this model helps lower hospital readmission rates and reduce per-patient healthcare costs.
Case managers are often the unsung heroes in a patient’s recovery. In conjunction with National Case Management Week, we asked for nominations for influential case managers who deserve some extra recognition. We were looking for professionals who are passionate about their work and go the extra mile for their patients. We found all that and more.