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.