Mrs. Harrison, a 75-year-old widow, entered an urban academic medical center through the emergency department after she fell in her garden and broke her hip. Once at the hospital, she admi
Mrs. Harrison, a 75-year-old widow, entered an urban academic medical center through the emergency department after she fell in her garden and broke her hip. Once at the hospital, she admitted she had not been taking the best care of her diabetes, and her chronic obstructive pulmonary disease caused her trouble occasionally, especially with all the time she spent in her garden. After five days as an inpatient at the hospital and a brief stay in inpatient rehabilitation, Mrs. Harrison returned home under the care of a home health agency, with directions to take ten medicationssome of them new to her regimen. Mrs. Harrisons goal was to be able to tend her garden again. The care teams goals were to control her diabetes and ensure her recovery after hip surgery. Once home, the situation deteriorated.Mrs. Harrisons community primary care physician had no idea she had been hospitalized or what had happened with her in-hospital care. Mrs. Harrisons two childrennever the best of friendscouldnt agree on how to manage her care, and her son, who serves as the primary caregiver, had to return to work even though he had been promised time off to care for his mother. As a result, Mrs. Harrison had no transportation to her follow-up medical appointments. Someone told her there might be a community agency with people who could drive her to the appointments, but Mrs. Harrison didnt know who to contact or how to set this up.Additionally, Mrs. Harrisons home health agency caregivers didnt show up on time, or as expected. When Mrs. Harrison left rehab for home, she had been given a list of medications, but now she wasnt sure what medications to continue or stop taking. She didnt particularly care anyway, since she couldnt afford all of the medications. Mrs. Harrison was especially confused when her medical bills began arriving: she didnt know what her insurance would cover or where to turn for answers. She was having difficulty coping with post-surgery mobility changes and was becoming increasingly depressed because she could not get around as she had before. Mrs. Harrison felt terribly isolated now that she was homebound; worse, she was terrified to go into her beloved garden because she thought she might fall again and have to return to the hospital.
What do you think attributed to this poor experience?
What role should nurses play in improving care transitions?
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