Diane's Patient

Coordination of Care Helps Patient Turn Corner

Once in a while, coordinating a patient’s care produces an outcome that exceeds the expectations of everyone involved.

That was the case for a 78-year-old woman who had surgery for lung cancer. The patient had been unsuccessful in being weaned from the ventilator while recovering from surgery, and was living with her daughter. The nurses suggested coordinated care.

Patient Care Manager Diane McNabb, RN, BSN, began working with the patient and her family. McNabb investigated what needed to happen for the patient to be admitted to a long-term vent facility and encouraged the family to look into options. “The problem was the ventilator facility would not accept her from home,” McNabb said.

One day, the patient’s daughter called to let McNabb know her mother hadn’t felt well. The patient’s OSF Home Care Services nurse was worried too.

She was taken to the hospital, where she was diagnosed with bilateral pneumonia. Because the patient’s family and McNabb had done their homework, upon discharge, she was able to go to a vent facility in Chicago. The patient did quite well. “She’s at rehabilitation right now, off the ventilator, and hoping with some physical therapy, she might be going home soon,” McNabb said.

The patient’s story is an almost textbook case of the benefits of coordination of care. It starts with a referral to a Patient Care Manager by nurses who noticed a need. It includes an engaged family, a motivated patient, and a number of professionals.

“It helped the family, because they only had to talk to one person, and I was familiar with her circumstances,” McNabb said. “It expedited her care, and she got the care she needed.”