Nurse helps patients take control of their health - KansasCity.com | Patient Self Management | Scoop.it
From www.kansascity.com - January 13, 2014 11:25 AM

When John "Chuck" Lenferink was being readied to fly from Campbell County Memorial Hospital to Denver in August, he turned to Angela Roesler and said, "This is going to kill me, isn't it?

The nurse looked at her 68-year-old chronically ill patient and told him "yes." If he didn't make some big changes, and soon, his chronic obstructive pulmonary disease (COPD) and congestive heart failure would be the death of him.

At the time, Lenferink was averaging one hospital stay and at least two emergency room visits per month. If he wasn't in the hospital for heart failure, it was for COPD. He was overweight, he couldn't breathe without oxygen and things were only getting worse.

Lenferink is stubborn. He'll be the first to say he doesn't like being told what to do. But faced with his own mortality, he knew he needed to listen to his favorite nurse.

"When he came home, he was a changed man," Roesler said.

Roesler loves being a nurse, and she also loves to teach. When the hospital decided to create a transition care program in May, she was ecstatic.

"It's the best of both worlds," she said.

Roesler had been an acute care nurse in the medical surgical department since 2009, but the change to a transition care nurse was easy.

"It's about the people," she said. "I love my patients, and I love this job."

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participating patients must be 65 or older and have one of the 10 most common diagnoses for readmitted patients, which are: congestive heart failure, COPD, coronary artery disease, diabetes mellitus, stroke, hip fracture, peripheral vascular disease, pulmonary embolism, chronic back pain and cardiac arrhythmia.

The nurses meet with at-risk patients while they're still in the hospital and then do a home visit once they are discharged.

"We don't do any acute assessments. We don't take blood pressures. We don't do what public health and home health agencies do," Roesler said. "We don't compete with them. We're kind of an adjunct to them."

The nurses act as a liaison between the patient, their doctors and the hospital. Their main goal is education and empowerment.

During the first home visit, the transition care nurses go over the discharge information that the hospital gave the patient and come up with an action plan.

The biggest challenge during the first visit is medication reconciliation, Roesler said. The nurse and patient go through all the patient's medications together and outline which pills the patient should be taking, how often and why.

... "This is a great program. I'm very thankful the hospital decided to do it," Roesler said. "It's definitely made a difference in the lives of real people." ...

It's not a time-driven program, so you get time with your patients, and you get to invest in them and in their success," she said.

Patients are taking control of their health, and the hospital is seeing its readmission rates go down for patients 65 and older.

"I think it's a good fit for every community, honestly," Roesler said. "It probably works well here because we are a community-focused hospital. We're it. So when people go to the hospital, they're going to come here, and when they go home they're going to look back to us to help them succeed at home."

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The hospital doesn't charge patients to use the service, and it's not getting reimbursed for it. The hope is that the program will work so well that the hospital will continue to provide the service once the grant stops paying the nurses' salaries.

"It's the right thing to do for the patients, and that's what I love," Roesler said. "If it's the right thing to do, then let's keep doing it."


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