Ann received a call from a patient who felt strongly that this nurse “saved his life”. He has been ill for an extended period and has had frequent and repeated hospital stays due to his multiple conditions. He became a remote patient management patient (RPM) and at the outset of his care, he was hypertensive and frustrated because his issues were not being effectively addressed when he was hospitalized.

Factors that have complicated this man’s care include that he is “out of network”, meaning he is not seen within our health system, making follow-up challenging because we do not have access to his hospital discharge information. At the outset, he was not a home health patient, also contributing to the challenges in coordinating community follow up. Ann has been instrumental in forming a therapeutic relationship that this patient has been able to trust and rely upon. This allowed her to work with him to regulate his medications and assist him in developing a consistent routine for his self-care responsibilities that he is comfortable and confident with. His trust in this nurse has allowed him to stabilize and increase his independence and self-management of ADLs and IADLs. Her immediate manager thinks that this nurse is in her “sweet spot” for remote patient care and makes a difference for patients in need.