The Integrated Care Approach

Nurse Christy Lloyd of UpStream was monitoring a patient who had been recently discharged from home health services. The patient, previously reliant on these services for PT/INR monitoring due to her warfarin therapy, found herself without this crucial support when the services were discontinued. Christy, realizing the gravity of the situation, particularly after the patient reported a last recorded INR of 7.0 (well above the therapeutic range of 2-3), acted swiftly to reconnect the patient with essential health services.

Initial Concern and Response: The patient contacted Christy, complaining of severe pain and inability to use her hand. Concerned about possible complications like a blood clot, despite the primary issue turning out to be a severe gout flare-up, Christy recommended immediate medical evaluation. She facilitated the patient's visit to her primary care provider (PCP) and ensured that the patient could secure transportation through her insurance benefits.

Hospitalization and Follow-Up Complications: After the initial hospital visit where gout was identified and treated, the patient, unfortunately, suffered a fall at home. She experienced a fracture after slipping in her bathroom while painting — a task she undertook soon after returning home from the hospital. This accident led to another hospital admission, this time for the treatment of the fracture. Christy visited the patient, offering support and assistance in navigating her new health challenges, including discussing rehabilitation options.

Ongoing Support and Care Coordination: Throughout these events, Christy maintained close communication with the patient's care team, arranging necessary follow-up appointments and exploring long-term care options, such as rehabilitation facilities. She also engaged with the patient's social worker to discuss potential placements that would suit her recovery needs.

Impact of Nurse Christy’s Intervention: Christy’s proactive and compassionate approach not only managed the immediate health issues but also strengthened the patient's trust in the healthcare system. By consistently being there for the patient, addressing each new challenge with the same dedication and concern, Christy exemplified UpStream’s core values of the union of head and heart, and the strength found in consistent, compassionate care.

This case highlights the vital role nurses like Christy play in patient care, particularly in managing complex cases where patients may feel overwhelmed and vulnerable. Christy's ability to coordinate across different healthcare services, ensuring her patient received comprehensive and continuous care, underscores the importance of a dedicated healthcare professional in achieving positive patient outcomes.